Thomas J. Butler PH.D RRT RPFT - Laboratory Exercises For Competency in Respiratory Care-F.a. Davis Company (201

Laboratory Exercises
for Competency in
Respiratory Care
Third Edition
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2679_FM_i-xxii.indd ii 07/02/13 4:49 PM
Laboratory Exercises
for Competency in
Respiratory Care
Third Edition
Thomas J. Butler, PhD, RRT-NPS, RPFT

Professor of Science
Rockland Community College
Suffern, New York
Staff Therapist
Kessler Institute for Rehabilitation
West Orange, New Jersey
NIOSH-Approved Spirometry Instructor
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F. A. Davis Company
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Copyright © 2013 by F. A. Davis Company
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Library of Congress Cataloging-in-Publication Data
Butler, Thomas J.
Laboratory exercises for competency in respiratory care / Thomas J. Butler. — 3rd ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-8036-2679-9
I. Title.
[DNLM: 1. Respiratory Therapy—Laboratory Manuals. 2. Respiratory Therapy—Problems and Exercises.
3. Clinical Laboratory Techniques—Laboratory Manuals. 4. Clinical Laboratory Techniques—Problems and
Exercises. WF 25]
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“For breath is life and if you breathe well you will live long on earth.”
Sanskrit Proverb
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Contents
Contributing Authors xiv CHAPTER 4 Sterilization and

Preface xv Disinfection 41
Acknowledgments xvi
Introduction xvii Exercises 42
Procedural Competency Evaluations Directory xxii Handling and Disposal of Infectious Equipment
and Waste 42
CHAPTER 1 Laboratory and Clinical Preparation of Equipment for Disinfection/
Safety 1 Sterilization by Autoclave, Ethylene
Oxide, Activated Glutaraldehyde, or
Exercises 1 Pasteurization 43
Professionalism 2 Monitoring Infection Control Procedures 44
AARC Guide to Professionalism Module 3 Laboratory Report 47
Medical Director or Physician Interaction 3 Procedural Competency Evaluation 49
Safety Considerations 3 Sterilization and Disinfection 49
Scene Survey 5
Patient Positioning 5
Laboratory Report 7
CHAPTER 5 Medical Record 51
Procedural Competency Evaluations 11 Exercises 52
Clinical Orientation 11 Chart Review, Patient Interview, and
Patient Positioning and Safety 13 History 52
Patient and Caregiver Training 15 Medical Record Documentation
(Charting) 54
CHAPTER 2 Communication and Cultural Laboratory Report 55
Diversity in Health Care 17 Procedural Competency Evaluations 61
Medical Record Review 61
Exercises 17
Medical Record Documentation 63
Communication 18
Patient Interview and History 65
Cultural Diversity 18
Case Study Presentation 67
Laboratory Report 19
CHAPTER 3 Infection Control 21 CHAPTER 6 Patient Assessment: Basic

Skills—Vital Signs 69
Exercises 22
Hand Washing 23 Exercises 70
Hand Sanitation 24 Primary Survey 70
Surgical Scrub 24 Secondary Survey 74
Barrier Precautions/Personal Protective Vital Signs 77
Equipment 24 Basic Pulse Oximetry 82
Laboratory Report 35 Laboratory Report 83
Procedural Competency Evaluations 37 Procedural Competency Evaluations 89
Hand Hygiene 37 Vital Signs: Pulse and Respiration 89
Patient Standard Precautions/Transmission-Based Blood Pressure 91
Isolation Procedures 39 Pulse Oximetry 93
vii
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viii • CONTENTS
CHAPTER 7 Patient Assessment: CHAPTER 11 Oxygen Therapy

Advanced Skills 95 Administration 153
Exercises 96 Exercises 154
Physical Assessment of the Chest 96 Oxygen Device Identification 154
Auscultation 101 Oxygen Therapy Administration 157
Laboratory Report 103 Air Entrainment (Venturi) Mask 162
Procedural Competency Evaluations 105 Troubleshooting 163
Physical Assessment of the Chest 105 Laboratory Report 165
Auscultation 107 Procedural Competency Evaluation 171
Common Performance Elements 109 Oxygen Therapy 171
CHAPTER 8 Bedside Assessment of CHAPTER 12 Humidity Devices 173

Pulmonary Mechanics 111
Exercises 174
Exercises 112 Bubble Humidifier 174
Obtaining Vt, Ve, and Va 113 Heat and Moisture Exchanger (HME) 175
Obtaining Negative Inspiratory Force and Wick Humidifier 176
Maximum Expiratory Pressure 114 Laboratory Report 179
Obtaining a Slow Vital Capacity 115 Procedural Competency Evaluations 183
Obtaining Peak Expiratory Flow Rate Humidification Therapy 183
Measurements 115 Humidification With Artificial Airway 185
Obtaining Data on Patients With Artificial
Airways 116 CHAPTER 13 Aerosol Generators 187
Procedural Competency Evaluation 121 Exercises 188
Bedside Pulmonary Mechanics 121 Large-Volume Nebulizer (LVN) 188
Aerosol Delivery Devices 190
CHAPTER 9 Oxygen Supply Ultrasonic Nebulizer (USN) 192
Gas Titration 193
Systems 123
Tandem Nebulizer Setup 194
Exercises 124 Laboratory Report 195
Medical Gas Cylinders 124 Procedural Competency Evaluation 199
Reducing Valves, Regulators, and Aerosol Generators: Large-Volume Nebulizers
Flowmeters 126 (LVNs) 199
Air Compressors 129
Blenders 130 CHAPTER 14 Cardiopulmonary
Bulk Storage Systems 130 Pharmacology Review 201
Zone Valves and Wall Outlets 131
Laboratory Report 133 Exercises 202
Procedural Competency Evaluations 139 Review of Respiratory Medications 203
Bulk Medical Gas Supply System 139 Calculation of Drug Dosages 204
Gas Pressure and Flow Regulation 141 Laboratory Report 205
Oxygen Blender 143 Procedural Competency Evaluation 209
Calculation of Drug Dosages 209
CHAPTER 10 Oxygen Analysis 145
CHAPTER 15 Aerosol and Medication
Exercises 146 Therapy 211
Oxygen Analyzer Components 146
Calibration of Oxygen Analyzers 146 Exercises 212
Oxygen Analysis 147 Small-Volume Nebulizers 212
Laboratory Report 149 Identification of Component Parts of Additional
Procedural Competency Evaluation 151 Delivery Devices 213
Oxygen Analysis 151
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C ONTENTS • ix
Specialty Nebulizers 216 CHAPTER 18 Adjunct Techniques for
Aerosol Medication Administration 218 Bronchial Hygiene 273
Filtered Nebulizers 222
Sputum Induction 222 Exercises 273
Laboratory Report 223 Directed Cough 274
Procedural Competency Evaluations 229 Vibratory Positive Expiratory Pressure (PEP)
Aerosol Medication Delivery: Nebulized Therapy 276
Solutions 229 Breathing Exercises 278
Aerosol Medication Delivery: Continuous Inspiratory-Resistive Muscle Training 280
Bronchodilator Nebulization 231 Laboratory Report 283
Aerosol Medication Delivery: MDI, Procedural Competency Evaluations 285
DPI 233 Breathing Exercises 285
Sputum Induction 235 Directed Cough 287
Positive Expiratory Pressure (PEP) Therapy/
CHAPTER 16 Hyperinflation Therapy Vibratory PEP 289
Techniques 237 Inspiratory Resistive Muscle Training 291
Intrapulmonic Percussion Ventilation (IPV) 293
Exercises 238
Incentive Spirometry 238 CHAPTER 19 Manual Resuscitators and
Identification of Intermittent Positive-Pressure Manual Ventilation 295
Breathing Machine Component Parts and
Controls 241 Exercises 296
Intermittent Positive-Pressure Breathing Circuitry Assembly and Disassembly of
Assembly 242 Resuscitators 296
Manipulation of Intermittent Positive-Pressure Pressure Relief Valves 297
Breathing Controls 243 Measurement of Pressures, Stroke Volumes, and
Intermittent Positive-Pressure Breathing Fio2 297
Therapy 244 Mouth-to-Mask Ventilation 298
Computerized Lung Simulator: Effect of Manual Ventilation With Mask 299
Compliance and Resistance Changes on Manual Ventilation With an Intubated
Intermittent Positive-Pressure Breathing Mannequin 299
Volumes 245 Manual Ventilation While Compressions Are
Laboratory Report 247 Performed 300
Procedural Competency Evaluations 253 Assisted Manual Ventilation in a Spontaneously
Incentive Spirometry 253 Breathing Subject 300
Intermittent Positive-Pressure Breathing Laboratory Report 301
(IPPB) 255 Procedural Competency Evaluation 307
Manual Ventilation 307
CHAPTER 17 Bronchial Hygiene: Chest
Physiotherapy 257 CHAPTER 20 Pharyngeal Airways 309
Identification of Lung Lobes and Identification of Airway Adjuncts 310
Segments 258 Selection and Insertion of a Nasopharyngeal
Postural Drainage 261 Airway 311
Chest Percussion 263 Selection and Insertion of an Oropharyngeal
Expiratory Vibration 264 Airway 312
Chest Physiotherapy Treatment 264 Laboratory Report 313
Laboratory Report 267 Procedural Competency Evaluation 317
Procedural Competency Evaluation 271 Pharyngeal Airway Insertion 317
Chest Physiotherapy 271
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x • C ONTENTS
CHAPTER 21 Suctioning 319 CHAPTER 25 Noninvasive Blood Gas

Monitoring 387
Exercises 320
Suction Equipment Identification 320 Exercises 388
Oropharyngeal Suctioning 322 Pulse Oximetry 388
Suction Kits 322 Capnography 390
Nasotracheal Suctioning 323 Transcutaneous Monitors 392
Endotracheal Suctioning 324 Laboratory Report 395
Endotracheal Suctioning With a Closed Procedural Competency Evaluations 403
System 325 Pulse Oximetry 403
Obtaining a Sputum Sample 326 Capnography/Capnometry 405
Laboratory Report 327 Transcutaneous Monitoring 407
Procedural Competency Evaluations 331
Endotracheal Suctioning 331 CHAPTER 26 Arterial Blood Gas
Nasotracheal Suctioning 333
Sampling 409
CHAPTER 22 Endotracheal Exercises 410
Intubation 335 Preparation of Blood Gas Kit Components 410
Modified Allen’s Test 412
Exercises 336 Performance of Arterial Puncture 414
Intubation Equipment and Preparation 336 Arterial Line Sampling 416
Orotracheal Intubation 341 Capillary Sampling 420
Securing an Endotracheal Tube 347 Laboratory Report 423
Laboratory Report 349 Procedural Competency Evaluations 427
Procedural Competency Evaluation 353 Arterial Puncture 427
Oral Endotracheal Intubation 353 Arterial Line Sampling 429
Capillary Sampling 431
CHAPTER 23 Tracheostomy Care 355
CHAPTER 27 Arterial Blood Gas Analysis
Exercises 356 and Maintenance 433
Tracheostomy Tubes 356
Tracheostomy Tube Care 360 Exercises 434
Laboratory Report 363 Blood Gas Analysis Using a Bench-Top Blood
Procedural Competency Evaluations 365 Gas Analyzer 434
Tracheostomy Care 365 Blood Gas Analysis Using Point-of-Care
Tracheostomy Tube Change 367 Testing 439
Co-oximetry 440
CHAPTER 24 Artificial Airway Care and Laboratory Report 441
Maintenance 369 Procedural Competency Evaluations 449
Bench-Top ABG Analyzer Maintenance 449
Exercises 370 ABG Analysis 451
Cuff Care 370
Resecuring and Repositioning of an CHAPTER 28 Blood Gas Interpretation
Endotracheal Tube and Oral Hygiene 372 and Calculations 453
Extubation 373
Airway Emergencies 373 Exercises 454
Laboratory Report 377 Interpretation of Arterial Blood Gas Values 454
Procedural Competency Evaluations 381 Calculation of Oxygenation Parameters 456
Cuff Care 381 Acid–Base Calculations 458
Extubation 383 Laboratory Report 459
Artificial Airway Care 385 Procedural Competency Evaluation 465
Arterial Blood Gas Interpretation 465
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C ONTENTS • xi
CHAPTER 29 Basic Chest X-ray Procedural Competency Evaluations 549

Interpretation 467 Electrocardiography 549
ECG Interpretation 551
Exercises 468
Identification of Positions 469 CHAPTER 32 Hemodynamic
Identification of Major Organs and Monitoring 553
Landmarks 470
Hyperinflation 472 Exercises 554
Pneumothorax 472 Identification of the Components of a
Atelectasis or Consolidation 473 Flow-Directed Pulmonary Artery
Endotracheal Tube Position 474 Catheter 554
Kyphoscoliosis 475 Assembly and Calibration of a Fluid-Filled
Infant and Pediatric Films 476 Monitoring System 555
Other Abnormal Patterns 478 Transducer Calibration 557
Laboratory Report 479 Identification of Pressure Waveforms 559
Procedural Competency Evaluation 489 Thermodilution Cardiac Output
Chest X-ray Interpretation 489 Determination 560
Hemodynamic Calculations 561
CHAPTER 30 Pulmonary Function Laboratory Report 565
Testing 491 Procedural Competency Evaluations 573
Hemodynamic Measurements 573
Exercises 492 Shunt Studies 575
Equipment Identification 492
Calibration and Maintenance of Spirometric CHAPTER 33 Phlebotomy 577
Equipment 494
Respiratory History 496 Exercises 578
Spirometry Screening 496 Identification of Veins 578
Calculation of Spirometric Results 503 Preparation of the Subject for
Postbronchodilator Study 506 Phlebotomy 579
Maximum Voluntary Ventilation 506 Preparation for Phlebotomy 579
Flow-Volume Loops 507 Phlebotomy Procedure 579
Laboratory Report 511 Phlebotomy Troubleshooting 580
Procedural Competency Evaluations 519 Laboratory Report 583
Screening Spirometry 519 Procedural Competency Evaluation 587
Flow-Volume Loop (FVL) 523 Venipuncture 587
Maximum Voluntary Ventilation (MVV) 525
Spirometry Screening Interpretation 527 CHAPTER 34 Intravenous Insertion
and Maintenance 589
CHAPTER 31 Electrocardiography 529
Exercises 590
Exercises 530 Identification of Veins and Catheter
Cardiac Anatomy 530 Parts 590
Identification of Electrocardiograph Machine Preparation of the Subject for Intravenous
Controls 531 Insertion 590
Preparation and Attachment of Limb Intravenous Insertion Procedure 590
Leads 532 Intravenous Rate Infusion Calculation 592
Preparation and Attachment of Precordial Intravenous Catheter Maintenance 593
(Chest) Leads 533 Intravenous Catheter Removal 593
Electrocardiograph Artifact 534 Laboratory Report 595
Cleanup Procedures 536 Procedural Competency Evaluation 599
Rate and Rhythm Interpretation 536 IV Insertion 599
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xii • C ONTENTS
CHAPTER 35 Chest Tube Drainage CHAPTER 39 Continuous Mechanical

Systems 601 Ventilation 647
Wet Chest Drainage Systems 602 Ventilator Assembly 648
Dry Chest Drainage Systems 603 Identification of Controls 649
Maintaining and Troubleshooting Chest Leak Testing 649
Drainage Systems 605 Determination of Tubing Compliance Factor and
Laboratory Report 607 Calculation of Lost Volume 649
Procedural Competency Evaluation 611 Pressure, Flow, Volume, and Time
Chest Drainage System Assembly 611 Relationships 650
CHAPTER 36 Bronchoscopy
Assisting 613 CHAPTER 40 Ventilator Modes 655
Identification of Components 614 Control and Assist/Control 657
Preparation of the Patient for Pressure Control Inverse I:E Ratio 659
Bronchoscopy 615 Synchronized Intermittent Mandatory
Equipment Preparation for Bronchoscopy 615 Ventilation 659
Bronchoscopy Procedure 616 Positive End-Expiratory Pressure/Continuous
Bronchoscopy Recovery 617 Positive Airway Pressure 660
Bronchoscopy Complications 617 Pressure Support Mode 661
Laboratory Report 619 Advanced Modes Using Targeting Schemes 662
Procedural Competency Evaluation 623 Laboratory Report 665
Bronchoscopy Assisting 623
CHAPTER 41 Ventilator Initiation 679
CHAPTER 37 Noninvasive
Exercises 680
Ventilation 625
Setting Alarm Parameters 680
Exercises 626 Ventilator Initiation 682
Negative-Pressure Ventilator 627 Circuit Changes 683
Continuous Positive Airway Pressure Setup 628 Laboratory Report 685
BiPAP Setup 630 Procedural Competency Evaluations 695
Laboratory Report 633 Adult Ventilator Initiation 695
Procedural Competency Evaluation 637 Ventilator Circuit Change 697
CPAP/BiPAP Initiation (Noninvasive
Ventilation) 637 CHAPTER 42 Patient-Ventilator
System Care and
CHAPTER 38 Pressure Ventilators 639 Maintenance 699
Identification of an Adult Breathing Circuit and Basic Ventilator Monitoring 700
Leak Testing 640 Data Generation for Evaluation of Patient
Pressure, Flow, Volume, and Time Status 702
Relationships 641 Waveform Identification and Interpretation 703
Initiation and Monitoring 642 Setting Modification and Documentation 708
Laboratory Report 643 Laboratory Report 711
Procedural Competency Evaluation 719
Adult Patient-Ventilator System Care 719
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C ONTENTS • xiii
CHAPTER 43 Discontinuation CHAPTER 46 Respiratory Care in

of Mechanical Alternate Settings 767
Ventilation 721
Exercises 768
Exercises 722 Long-Term Oxygen Therapy 768
Weaning Modalities 722 Portable Liquid Oxygen Systems 770
Assessment During Weaning 722 Oxygen Concentrators 771
Weaning Protocols 723 Oxygen-Conserving Devices 771
Computer-Directed Weaning Options 723 Home Disinfection Techniques 773
Laboratory Report 725 Home Care/Portable Ventilator Initiation 773
Procedural Competency Evaluation 731 Discharge Planning 774
Ventilator Weaning Protocols 731 Home Evaluation Assessment 774
CHAPTER 44 Neonatal/Pediatric Procedural Competency Evaluations 785
Oxygen-Conserving Devices 785
Respiratory Care 733
Discharge Planning 787
Exercises 734 Home Care Evaluation 789
Patient Assessment in the Newborn 734 Home Care Ventilation 791
Nasal Continuous Positive Airway Pressure Home Oxygen Administration 793
for the Infant 737 Home Nebulizer Administration 795
Laboratory Report 739 Home CPAP Application 797
Procedural Competency Evaluations 743 Home Apnea Monitoring 799
Nasal CPAP Initiation 743
Oxygen Hood 745
APPENDIX A: Normal and Critical
Oxygen Tent 747
Values, Formulas, and
Rules of Thumb 801
CHAPTER 45 Neonatal/Pediatric
Ventilation 749
Exercises 750 APPENDIX B: Common Performance
Time-Cycled/Pressure-Limited Ventilators 750 Elements 809
High-Frequency Ventilators 751
Initiating Mechanical Ventilation in an
Infant 752 Glossary 811
Pediatric Ventilation 754
Procedural Competency Evaluations 763
Neonatal/Pediatric Ventilator Initiation 763 Index 821
Neonatal/Pediatric Patient-Ventilator System
Care 765
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Contributing
Authors
Lisa Shultis, BS, RRT

Director, Respiratory Care Program
SUNY Sullivan County Community College
Loch Sheldrake, New York
Dianne A. Adams, MA, RRT, NPS

Assistant Chair of Allied Health and Program Director, Respiratory Therapy Program
County College of Morris
Randolph, New Jersey
xiv
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Preface
The third edition of this laboratory manual continues the teaching philosophy outlined in the
first and second editions. Critical thinking skills cannot be taught or achieved by cookbook
methodologies that simply have students assemble equipment and follow prescribed steps. These
do not achieve any goal except slavish adherence to a procedure that has no variability. Clearly,
the laboratory setting is the ideal location for the exploration of and experimentation with
various pieces of equipment.
The demands placed on clinical educators in today’s health-care environment are challenging as
well as daunting. Hopefully, a substantially meaningful laboratory experience where students
are challenged to develop cognitive, psychomotor, and affective skills will help the students
achieve the clinical proficiency necessary for success.
For this new edition, my contributing authors and I have updated the exercises to reflect changes
in practice while still providing the exploration of basic therapeutics. I have reorganized the
chapters covering diagnostics and special procedures to group the cardiopulmonary chapters
together. We included additional material on mechanical ventilation, and we incorporated the
latest ATS/ERS standards into the spirometry chapter. Lastly, we added new critical thinking
questions that emphasize information gathering and calculations.
Thomas J. Butler
xv
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Acknowledgments
The third edition of this manual was no less daunting than the first two editions. It too reflects
the work of many individuals. It would be a grave injustice not to thank…
• Andy McPhee, Quincy McDonald, and the entire F.A. Davis staff for their counsel,
commitment, and support.
• Dean DeChambeau, a marvelous developmental editor, for his insight, attention to detail,
and infinite patience.
• Dianne Adams and Lisa Shultis for the contribution of their expertise to the various chapters
they revised.
• The respiratory care programs that continue to use this text and have contributed
suggestions for its improvement.
xvi
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Introduction
TO THE STUDENTS
For many of you, enrollment in a respiratory care program may represent your first exposure
to professional education. As with any field, you must master a body of specialized knowledge.
Professional health-care education, however, is unique in that it requires you to skillfully apply
this knowledge in practical settings, often with the patient’s life in the balance. In addition, you
must develop specific interpersonal skills and behavioral attributes for effective professional
competence. The credentialing examinations, added clinical responsibility, and skills required
by potential employers are challenging, to put it mildly.
Laboratory exercises are an essential and integral part of health professions education. Any labo-
ratory text must include practice of the basic cognitive, psychomotor, and affective principles re-
lated to respiratory practice. The text is designed to provide you with the hands-on and commu-
nication skills necessary to integrate theory and clinical practice. This edition includes additional
exercises to cover the expanded role of the respiratory care practitioner (RCP). It is not intended
to be an all-inclusive compendium of tasks and respiratory equipment or a replacement for the
theoretical content found in your other respiratory care texts. You can use this book as a comple-
mentary tool in conjunction with other resources as a study and evaluation tool in the preclinical
or clinical setting.
The laboratory should be used as a risk-free environment for formative development of respira-
tory care skills. You will be asked to assess your “patients,” perform procedures, manipulate
equipment, and determine settings to observe and experience the resulting consequences. The ex-
ercises are designed to promote critical thinking rather than solely to practice psychomotor skills.
Some of the exercises are designed so that you purposely set up or use equipment incorrectly in
order for you to differentiate the right way from the wrong way. It is better to explore these situ-
ations in a controlled laboratory setting than in a patient care environment. The text is flexible
and general enough to cover the principles without being too specific as to particular brand name
products, which may not always be available.
The manual is formatted so that most chapters can be completed in one or more formally sched-
uled 2-hour laboratory periods. The sequence of chapters is not intended to be rigid and your in-
structor may assign the chapters to suit curricular needs. The text is, however, detailed enough so
that you could perform the exercises with minimal supervision in an independent practice setting
as a supplement or replacement for a scheduled laboratory period.
Each chapter includes:
• An introduction
• Objectives
• Key terms
• A list of required equipment
• Exercises appropriate to content
• Tables summarizing normal, abnormal, and critical values where appropriate
• References
• A laboratory report form
• Procedural competency evaluations (PCEs) for each skill assessment
• A performance rating scale form for each PCE
The key terms are not limited to vocabulary found in the text of the chapter. Terms that may be
necessary to communicate effectively, understand concepts, or answer chapter questions are also
xvii
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xviii • INTRODU CT I ON
included. All are defined in the glossary. The objectives are not limited to manipulation of equip-
ment, but are geared toward both basic and higher-level cognitive, psychomotor, and affective
skills. Troubleshooting exercises and verbal and written communication exercises are included
where appropriate. Charting of procedures performed is extensively practiced.
Efficient use of laboratory time depends on your adequate preparation. Read the assigned chapter
before the scheduled laboratory session, and review the related didactic information. Practice all
the skills as frequently as necessary in order to master the art of communication and the perfor-
mance of psychomotor tasks. This will require additional independent laboratory time outside of
scheduled sessions. Do not expect that you will be competent after performing a skill once or
twice in a laboratory setting or after watching someone else perform the task.
LABORATORY R EPOR TS
The Laboratory Report form documents data collection during the exercises. The report includes
questions and clinically relevant scenarios to enhance critical thinking skills, integrate theory with
practice, and focus on the affective domain. If an exercise requires documentation of data or ob-
servations, the exercise number correlates with the corresponding number in the laboratory report
form. Document your data collection and observations completely and neatly. Exercises that do
not require any documentation do not have a corresponding laboratory report.
The laboratory session is intended for hands-on practice. You should complete questions and cal-
culations that do not involve direct contact with equipment or performance of procedures outside
of laboratory time. Write out your answers to the Critical Thinking Questions neatly or print out
your answers and attach them to the laboratory report (include the question and corresponding
number in the attachment to help your instructor grade your answers).
You will not be able to answer the questions at the end of each laboratory report solely from per-
forming the laboratory exercises and procedures, nor from a single reference source. This is by
design. You are expected to research a variety of supplemental readings. Keeping current with the
literature is an important part of professional development.
The placement of this report allows for easy removal so that it may be submitted to the instruc-
tor, leaving the remainder of the manual intact for study, review, and additional practice. You are
expected to complete the laboratory report, including all questions, and submit the report to your
instructor by the assigned date. Deductions for late reports, according to individual programs’
policies, are likely. Keep the remainder of the laboratory chapter intact. You may wish to keep re-
turned graded laboratory reports for further review and study.
PROCEDURAL C OMP ETEN CY EVAL UAT I O N S

Evaluation is a vital link in the teaching–learning process. A procedural competency evaluation
(PCE) involves a demonstration of a specific respiratory care skill in conjunction with an assess-
ment of your understanding and ability to apply the related theory. The PCEs are intended to be
used as study tools as well as evaluation tools. The PCEs are not brand specific regarding equip-
ment, but are intended to verify that you can select, obtain, assemble, verify function, and correct
malfunctions of the required equipment for the procedure. Your evaluator will assess the manner
in which you interact with patients or other health-care professionals. You should be able to react
appropriately to adverse reactions, notify appropriate personnel, and make recommendations to
modify the patient care plan according to patient needs.
TO THE INSTRUCTORS
LABORATORY SETUP
The list of required equipment is provided for each chapter. However, there are materials that
should be provided for every activity:
• 50-psi gas source
• Alcohol prep pads
• Flowmeter
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INTR ODUC TION • xix
• 4×4 gauze
• Gloves, nonsterile, latex free, and in various sizes
• Goggles or face shields
• Hand sanitizer
• Human patient simulator (if available)
• Large-bore corrugated tubing, 6-inch and 6-foot lengths
• Oxygen nipple adapter
• Small-bore oxygen tubing
The Instructor’s Guide also provides guidance and direction for setting the lab exercises. Copies
of the lab reports contain suggested point values for each exercise.
P R OCEDUR AL C OMP ETENC Y E VA LU AT I O N S

As noted earlier for the students, the text includes Procedural Competency Evaluation (PCE)
forms. The PCE for each skill is available in its respective chapter for laboratory or clinical appli-
cations. The task to be evaluated is identified on each PCE form. The evaluator may be a peer or
an instructor. Each competency evaluation consists of a list of steps in the task or procedure, defi-
nitions of acceptable performance, a scoring scheme, and a performance rating form. The PCE
form may be used for student review or peer evaluation, preclinical evaluation in the laboratory
setting, and clinical competency evaluation. Multiple copies should be made for these purposes.
The skills included represent the most common entry-level and advanced procedures required of the
respiratory care practitioner (RCP). In every procedural competency, certain performance elements
are required to meet national practice standards and provide quality patient care. The three main
categories of behaviors are Equipment and Patient Preparation, Assessment and Implementation,
and Follow-up. These include steps that are common to almost all respiratory care procedures.
Patient and Equipment Preparation
1. Verifies, interprets, and evaluates physician’s order or protocol
2. Scans the chart for any other pertinent data and notes, including diagnosis, medications,
therapies, and radiographic and other laboratory results
3. Washes hands or applies disinfectant
4. Selects, obtains, and assembles equipment correctly, and verifies function
5. Troubleshoots equipment and corrects malfunctions if indicated
6. Applies personal protective equipment (PPE); observes standard precautions and
transmission-based isolation procedures as appropriate
7. Identifies the patient, introduces self and department
8. Explains the purpose of the procedure and confirms patient understanding
Assessment and Implementation
9. Positions the patient for procedure
10. Assesses the patient including, where applicable, vital signs, Spo2, breath sounds, and
ventilatory status
Follow-up
11. Reassesses and reinstructs patient as needed
12. Ensures patient comfort and safety
13. Maintains/processes equipment
14. Disposes of infectious waste and washes hands or applies disinfectant
15. Records the pertinent data in chart and departmental records
16. Notifies the appropriate personnel and makes any necessary recommendations or
modifications to the patient care plan
Detailed steps are included for each procedure. The sequence may occasionally vary, but there
is usually a critical order for many steps. In more advanced skills, these common performance
elements have been streamlined into a single step, thus avoiding needless repetition. The PCEs
also address legal issues, such as verifying orders or respiratory protocols, patient identification,
compliance with OSHA regulations or CDC guidelines for infection control, and documentation.
All procedures are in compliance with the AARC Clinical Practice Guidelines (CPGs). A complete
alphabetical list of all PCEs in the text follows this introduction for easy reference. Additional
PCEs can be downloaded from DavisPlus (http://davisplus.fadavis.com).
2679_FM_i-xxii.indd xix 07/02/13 4:49 PM

xx • INTR ODUC T I ON
CLINICAL PE R FOR MAN C E EVALUATIO N
The student’s evaluation of a particular skill now includes objective scoring of the cognitive,
psychomotor, and affective domains using the Clinical Performance Evaluation (CPE) sheet
following each PCE. When both the student and the instructor believe that a skill has been mas-
tered, an evaluation session may be scheduled. It therefore follows that students should be fully
prepared to demonstrate mastery without assistance of any kind. If it becomes necessary for the
evaluator to intervene either to safeguard the patient’s welfare or to expedite completion of the
procedure, additional practice (laboratory or clinical) will be required and a repeat evaluation
session will be necessary.
The student should fill out his or her complete name and the date of the evaluation on the PCE,
including the year. Describe the conditions, such as the level of patient cooperation; whether the
procedure was performed on an infant, child, or adult; unexpected emergencies; if the procedure
was simulated on a peer; or any other applicable variables. Identify the equipment used (e.g., a
particular brand of ventilator or spirometer).
The scoring criteria reflect what the student knows, does, and says. Students should demon-
strate knowledge of essential concepts as part of the procedural evaluation. The ability to
apply, analyze, and synthesize didactic information in the clinical setting is needed for higher
ratings. The procedures must be completed in a reasonable time frame consistent with patient
safety and national time frame standards. Performance is rated as independent, minimal super-
vision required, competent, marginal, or dependent. The scoring guidelines for each level of
performance are as follows:
• Independent: Near-flawless performance; minimal errors; able to perform without
supervision; seeks out new learning; shows initiative; A = 4.7–5.0 average
• Minimally Supervised: Few errors, able to self-correct; seeks guidance when appropriate;
B = 3.7–4.65
• Competent: Minimum required level; no critical errors; able to correct with coaching; meets
expectations; safe; C = 3.0–3.65
• Marginal: Below average; critical errors or problem areas noted; would benefit from
remediation; D = 2.0–2.99
• Dependent: Poor; unacceptable performance; unsafe; gross inaccuracies; potentially harmful;
F = <2.0
The instructor also has the option of choosing “not applicable” for any step. If the student can
correct noncritical errors without endangering patient safety or the validity of data, without
prompting from the evaluator, a satisfactory rating should result.
Satisfactory completion of a given PCE requires more than a rigid adherence to the listed steps on
the PCE. The performance criteria include behaviors in addition to the procedural steps. Students
are graded on these criteria using the same scale. A rating of 5 represents a near-flawless perfor-
mance while a 1 represents a performance fraught with error or dangerous behavior. Each item
will be rated individually and independently.
Rate the student’s performance using the score of 3 as the starting point. This represents average
or minimal competency and indicates that the student’s performance is safe and effective without
critical errors. The student is able to self-correct errors, report information accurately, and dem-
onstrate awareness of his or her own limitations. No directive cues or prompting is needed, but
the student may require supportive cues. The student may use some unnecessary energy to com-
plete the activity and may occasionally be anxious and distracted as skills become more complex.
A score of 1 indicates critical errors and unsafe practice, inability to demonstrate the behavior, or
potentially harmful behaviors being noted frequently. The student demonstrates a lack of under-
standing of the basic concepts and an inability to apply concepts or adapt to changing situations
and is unaware of his or her limitations. The student lacks organization, appears frozen or is
nonproductive, and requires continuous directive cues.
A score of 2 is below minimal competency. Performance is marginal or below average, and
although the student may perform safely under direct supervision, performance is not always
accurate, and some critical errors are noted. Improvement is needed and significant problem
areas still exist.
A score of 4, above average or supervised performance, indicates that the student requires no
directive prompting or correction, is able to self-correct errors, and is aware of his or her own
limitations. Minimal supportive cues may be needed and some unnecessary energy may be used
to complete activities.
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INTR ODUC TION • xxi
The highest score of 5 is reserved for flawless performance, far exceeding the expected level
of performance. This is intended for the student who has superior knowledge, judgment, indepen-
dence, and initiative. The student contributes to his or her own and the group’s learning, spends
minimal time on tasks, applies theory and rationale accurately each time, and uses subtle cues
to modify his or her own behaviors.
The summary performance evaluation and recommendations section provides recommendations
to the student. Therefore, the student should have no question as to the result of the performance.
The evaluator should review the completed PCE evaluation with the student, emphasizing positive
performance elements as well as areas needing improvement. Both evaluator and student should
sign the completed PCE.
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Procedural
Competency
Evaluations
Directory
ABG Analysis ................................................................451 Home Oxygen Administration ......................................793
Adult Patient-Ventilator System Care ............................719 Humidification Therapy ................................................183
Adult Ventilator Initiation .............................................695 Humidification With Artificial Airway ..........................185
Aerosol Generators: Large-Volume Nebulizers Incentive Spirometry .....................................................253
(LVNs)......................................................................199 Inspiratory Resistive Muscle Training ...........................291
Aerosol Medication Delivery: Continuous Intermittent Positive-Pressure Breathing (IPPB) .............255
Bronchodilator Nebulization ....................................231 Intrapulmonic Percussion Ventilation (IPV) ...................293
Aerosol Medication Delivery: MDI, DPI .......................233 IV Insertion ...................................................................599
Aerosol Medication Delivery: Nebulized Solutions........229 Manual Ventilation .......................................................307
Arterial Blood Gas Interpretation ..................................465 Maximum Voluntary Ventilation (MVV) ......................525
Arterial Line Sampling ..................................................429 Medical Record Documentation......................................63
Arterial Puncture ...........................................................427 Medical Record Review ..................................................61
Artificial Airway Care ...................................................385 Nasal CPAP Initiation ...................................................743
Auscultation ..................................................................107 Nasotracheal Suctioning................................................333
Bedside Pulmonary Mechanics ......................................121 Neonatal/Pediatric Patient-Ventilator System Care ........765
Bench-Top ABG Analyzer Maintenance ........................449 Neonatal/Pediatric Ventilator Initiation.........................763
Blood Pressure.................................................................91 Oral Endotracheal Intubation .......................................353
Breathing Exercises .......................................................285 Oxygen Analysis ...........................................................151
Bronchoscopy Assisting .................................................623 Oxygen Blender.............................................................143
Bulk Medical Gas Supply System ..................................139 Oxygen-Conserving Device ...........................................785
Calculation of Drug Dosages.........................................209 Oxygen Hood ...............................................................745
Capillary Sampling ........................................................431 Oxygen Tent .................................................................747
Capnography/Capnometry ............................................405 Oxygen Therapy ...........................................................171
Case Study Presentation ..................................................67 Patient and Caregiver Training ........................................15
Chest Drainage System Assembly ..................................611 Patient Interview and History..........................................65
Chest Physiotherapy ......................................................271 Patient Positioning and Safety .........................................13
Chest X-ray Interpretation ............................................489 Patient Standard Precautions/Transmission-Based
Clinical Orientation ........................................................11 Isolation Procedures ...................................................39
Common Performance Elements ...................................109 Pharyngeal Airway Insertion .........................................317
CPAP/BiPAP Initiation (Noninvasive Ventilation) ..........637 Physical Assessment of the Chest...................................105
Cuff Care ......................................................................381 Positive Expiratory Pressure (PEP)
Directed Cough .............................................................287 Therapy/Vibratory PEP ............................................289
Discharge Planning........................................................787 Pulse Oximetry........................................................93, 403
ECG Interpretation .......................................................551 Screening Spirometry.....................................................519
Electrocardiography ......................................................549 Shunt Studies.................................................................575
Endotracheal Suctioning................................................331 Spirometry Screening Interpretation ..............................527
Extubation ....................................................................383 Sputum Induction..........................................................235
Flow-Volume Loop (FVL) .............................................523 Sterilization and Disinfection ..........................................49
Gas Pressure and Flow Regulation ................................141 Tracheostomy Care .......................................................365
Hand Hygiene .................................................................37 Tracheostomy Tube Change ..........................................367
Hemodynamic Measurements .......................................573 Transcutaneous Monitoring ..........................................407
Home Apnea Monitoring ..............................................799 Venipuncture .................................................................587
Home Care Evaluation ..................................................789 Ventilator Circuit Change .............................................697
Home Care Ventilation .................................................791 Ventilator Weaning Protocols ........................................731
Home CPAP Application ...............................................797 Vital Signs: Pulse and Respiration ...................................89
Home Nebulizer Administration ...................................795
xxii
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CHAPTER Laboratory and
Clinical Safety
INTRODUCTION Whether in the laboratory or clinical setting, successful and positive experiences can only
occur if the student is well oriented into those settings. Employers spend the necessary
time and resources to ensure that employees are informed about safety in the work
environment. Respiratory care students should also be thoroughly informed about safety.
In addition, patient safety has become a national health concern as well as a major focus
of The Joint Commission. Patient safety must be a primary concern and must be stressed
at the onset of the clinical experience and reinforced thereafter.
OBJECTIVES 1. Relate the safety information contained on an MSDS sheet.

Upon completion of this 2. Perform a scene survey to establish the safety of a setting.
chapter, you will be able to:
3. Identify potential safety hazards in the laboratory or clinical setting and formulate corrective
actions.
4. Safely position a patient in the semi-Fowler’s position.
KEY TERMS
Flower’s position OSHA semi-Fowler’s position
hazardous material professionalism supine
MSDS sheet safety surrogate
Exercises
E Q U IP M E N T R E Q U IR E D
F Call bell
F Clinical agency and/or college safety or policy and procedure manual
F Hospital bed (or equivalent)
F Mannequin
F Pillows
2679_Ch01_001-016.indd 1 07/02/13 4:42 PM

2 • LABOR ATORY E XE RCI SE S F OR COM PE T E NCY I N R E S P I R AT O RY C A R E
EXERCISE 1.1 PROFESSIONALISM
The instructor will review 1. Laboratory schedule, availability, hours, open-lab

the following with you: 2. Rules for equipment use, storage and cleanup, eating and drinking in the lab area, oxygen
or compressed air usage
3. Reporting mechanisms
4. Punctuality
5. Dress and personal hygiene codes
6. Professional responsibility
The following basic rules 1. You should read the assignments before the start of each laboratory session. It is important
should be observed in order that you have a familiarity with terminology, equipment, and the types of exercises before
to make the laboratory a beginning any practice.
safe and meaningful 2. For any independent practice, you must sign in and out according to laboratory policies.
experience: 3. Smoking, eating, and drinking should not be allowed in the laboratory area. Food should
not be stored in the laboratory area. “No Smoking” signs should be posted even though
most educational and health-care institutions are “smoke free.”
4. Applying cosmetics or contact lenses should not be permitted in the laboratory area.
5. All equipment must be handled with care. Compressed gas cylinders must never be left free-
standing. Oil, grease, and any other flammable materials should not be used near oxygen
equipment.
6. Equipment should not be handled before the instructor gives instruction in its use.
7. Any defective or broken equipment must be reported immediately to the laboratory instruc-
tor or supervisor. This includes any equipment with frayed wires or loose connections. Im-
mediately report any electrical equipment that is sparking or that causes a shock.
8. Personal protective equipment (PPE) should be used as required in the exercises.
9. Handle all chemicals and disinfecting solutions as instructed. MSDSs should be available for
all substances kept in the laboratory.
10. Needles should not be recapped with two hands. All sharps should be disposed of in the
puncture-proof containers provided.
11. Any injury or accidental needle stick should be reported immediately to the instructor or
laboratory supervisor.
12. You will be responsible for cleaning up after each laboratory session. The laboratory per-
sonnel are not substitutes for housekeeping or mothers. Discard any papers or disposable
equipment and supplies properly before leaving the laboratory.
13. Make sure all equipment is turned off and returned to its proper place before leaving.
14. Any disposable equipment that is assigned to you for repeated use (such as oxygen devices,
nose clips, or mouthpieces) should be stored in a designated container and labeled with the
student’s name. It is your responsibility to maintain this equipment and have it available for
the laboratory exercises.
15. Never remove equipment from the laboratory unless instructed to do so.
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C H A P T E R 1 | LA B O R AT O RY AND C LINIC AL S AFETY • 3
EXERCISE 1.2 AARC GUIDE TO PROFESSIONALISM MODULE
1. Go to the AARC website and review the presentation on professionalism at www.aarc.org/

resources/professionalism.
2. You should read the following statements:
A. Statement of Ethics and Professional Conduct
B. Role Model Statement
C. Position Statement on Diversity
3. Review the following questions from the module:
A. What behaviors have you observed among health-care providers that you consider
unprofessional?
B. Are there behaviors that you consider essential to professionalism that were not
addressed in the program?
C. What is the most important attribute of the professional you most admire?
4. Your instructor will split the class into smaller groups.
A. Engage in a 10- to 15-minute discussion.
B. Your group should appoint a designated recorder.
5. The student group recorders will share and discuss their small group conclusions.
EXERCISE 1.3 MEDICAL DIRECTOR OR PHYSICIAN INTERACTION
The instructor will have you listen to a 15- to 30-minute talk on professionalism and the respira-
tory care practitioner (RCP). Topics will include RCP–physician interaction; role of the RCP in
the physician practice, and the need for clear, unambiguous communication. Summarize the key
points on your laboratory report.
EXERCISE 1.4 SAFETY CONSIDERATIONS

EXER C ISE 1.4.1 ELEC TRIC A L S A FE T Y
Review the clinical agency or college policy and procedure manual regarding electrical safety.
Summarize the policies on your laboratory report.
EXER C ISE 1.4.2 F IRE S AF E T Y

Review the clinical agency or college policy and procedure manual regarding fire safety.
Summarize the policies on your laboratory report.
EXER C ISE 1.4.3 OS HA S TA N D A R D S

Review the clinical agency or college policy and procedure manual regarding OSHA standards for
workplace safety. Summarize the policies on your laboratory report.
2679_Ch01_001-016.indd 3 07/02/13 4:42 PM

EXERCISE 1 .4.4 HAZARDOUS MATERI A LS A N D MS D S S H E E T S

Locate the MSDS manual and compare its contents to the sample MSDS sheet shown in
Figure 1.1. Record health hazard data and special protection and precaution information
on your laboratory report.
Clorox Professional Products Company

1221 Broadway Material Safety
Oakland, CA 94612
Tel. (510) 271-7000 Data Sheet
I Product: CLOROX COMMERCIAL SOLUTIONS® CLOROX® BLEACH
Description: CLEAR, LIGHT YELLOW LIQUID WITH CHLORINE ODOR
Other Designations Distributor Emergency Telephone Nos.

Clorox Bleach for P&G Pro Line On-Premise Laundry Clorox Sales Company For Medical Emergencies, call 1-800-446-1014
Sodium Hypochlorite Solution 1221 Broadway For Transportation Emergencies, call
Oakland, CA 94612 Chemtrec 1-800-424-9300
II Health Hazard Data III Hazardous Ingredients

DANGER: CORROSIVE. May cause severe irritation or damage to eyes and Ingredient Concentration Worker Exposure Limit
skin. Vapor or mist may irritate. Harmful if swallowed. Keep out of reach of Sodium hypochlorite 6.0 - 7.35% Not established.
children. CAS # 7681-52-9
Some clinical reports suggest a low potential for sensitization upon exaggerated
exposure to sodium hypochlorite if skin damage (e.g., irritation) occurs during Sodium hydroxide < 0.2% 2 mg/m3 TLV-STELa
exposure. Under normal consumer use conditions the likelihood of any adverse CAS # 1310-73-2 2 mg/m3 PELb
health effects are low. a
TLV-STEL = ACGIH Threshold Limit Value - Short Term Exposure Limit
Medical conditions that may be aggravated by exposure to high concentrations b
PEL = OSHA Permissible Exposure Limit - Time Weighted Average
of vapor or mist: heart conditions or chronic respiratory problems such as
asthma, emphysema, chronic bronchitis or obstructive lung disease. None of the ingredients in this product are on the IARC, NTP or OSHA
carcinogen list.
FIRST AID:
Eye Contact: Hold eye open and rinse with water for 15-20 minutes. Remove
contact lenses, after first 5 minutes. Continue rinsing eye. Call a physician.
Skin Contact: Wash skin with water for 15-20 minutes. If irritation develops, call
a physician.
Ingestion: Do not induce vomiting. Drink a glassful of water. If irritation
develops, call a physician. Do not give anything by mouth to an unconscious
person.
Inhalation: Remove to fresh air. If breathing is affected, call a physician.
IV Special Protection and Precautions V Transportation and Regulatory Data

Hygienic Practices: Wear safety glasses. With repeated or prolonged use, DOT: Not restricted per 49CFR172.101(c)(12)(iv).
wear nitrile, neoprene, or butyl rubber gloves. Wash after contact with product.
IMDG: Not restricted per IMDG Code Page 0021 Paragraph 5.3.5.
Avoid breathing vapors.
IATA: Not restricted per IATA D.G.R. Special provision A3.
Engineering Controls: Use general ventilation to minimize exposure to vapor or
EPA - SARA Title III/CERCLA:
mist.
This product is regulated under Sections 311/312. This product contains no
chemicals regulated under Section 313 and contains sodium hypochlorite and
Work Practices: Avoid eye and skin contact and inhalation of vapor or mist.
sodium hydroxide which are regulated under Section 304/CERCLA.
KEEP OUT OF THE REACH OF CHILDREN. TSCA Status: All components of this product are on the TSCA Inventory.
VI Spill Procedures/Waste Disposal VII Reactivity Data

Spill Procedures: Absorb and containerize. Wash residual down to sanitary Stability: Stable under normal use and storage conditions.
sewer. Contact the sanitary treatment facility in advance to assure ability to
process washed down material. Reactivity: Reacts with chemicals such as acid toilet bowl cleaners, rust
removers, acids, vinegars and ammonia-containing products to produce
Waste Disposal: Disposal must be made in accordance with applicable federal,
hazardous gases, such as chlorine and other chlorinated compounds.
state and local regulations.
Storage/Disposal: Do not use or store near heat or open flame.
VIII Fire and Explosion Data IX Physical Data

Boiling point..................................................................212°F/100°C (decomposes)
Fire Extinguishing Agents: Water spray, dry chemical, carbon dioxide (COs)
Specific gravity (H2O=1, 21°C) ....................................................................... ~1.10
Flashpoint: >200°F (closed cup).
Solubility in water ......................................................................................Complete
Unusual Fire and Explosion Hazards: None.
pH.................................................................................................................... ~11.4
©1963, 1991 THE CLOROX COMPANY

DATA SUPPLIED IS FOR USE ONLY IN CONNECTION WITH OCCUPATIONAL SAFETY AND HEALTH DATE PREPARED 7/2007
Figure 1.1. Material safety data sheet (MSDS) for Clorox. (Courtesy of the Clorox Co., Oakland, CA.)
2679_Ch01_001-016.indd 4 07/02/13 4:42 PM

EXERCISE 1.5 SCENE SURVEY

EXER C ISE 1.5.1 IDEN TIFIC AT I O N O F S A FE T Y H A Z A R D S — D I A G R A M
Identify at least 10 safety hazards in Figure 1.2. Record the list on your laboratory report.
Figure 1.2. Scene survey.

Identification of safety hazards.
EXER C ISE 1.5.2 IDEN TIFIC AT I O N O F S A FE T Y H A Z A R D S — S C E N A R I O

Your instructor will prepare Performs the following:
the scene to include possible 1. When entering the “patient” area, quickly observe your surroundings. Look up, down, and
safety hazards near a all around. Take a maximum of 45 seconds.
“patient” in bed. 2. Turn away from the scene and record on your laboratory report all your recollections about
the scene for the following factors:
A. Was the scene safe? List any hazardous conditions.
B. What equipment did you see in the immediate area?
C. Were the conditions conducive to patient comfort?
i. What were the environmental conditions like? Describe the temperature, humidity,
lighting, and cleanliness.
ii. Were the patient’s material needs within easy reach?
EXERCISE 1.6 PATIENT POSITIONING
Using a mannequin or fellow 1. Ensure that no peripheral line or oxygen tubing is taut or caught on the side rails.
student, place him or her in 2. Lower the side rails and position the “patient” properly in the supine position.
a semi-Fowler’s position. 3. Adjust any pillows or blankets as necessary.
4. Elevate the head of the bed to a 45-degree angle.
5. Raise and secure side rails.
6. Ensure that the nurse call bell is within reach.
7. Ensure that all other patient-required materials are in reach.
8. Reinspect the scene before leaving to make sure there are no unsafe conditions.
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2679_Ch01_001-016.indd 6 07/02/13 4:42 PM
Laboratory Report
CHAPTER 1: LABORATORY AND CLINICAL SAFETY
Name: Date:
Course/Section: Instructor:
Data Collection
EXERCISE 1.2 AARC Guide to Professionalism Module
S MA L L G R O U P D IS C U S S IO N NOTES
Recorder: ___________________________________________________________________________________________________
Group members: ______________________________________________________________________________________________
Unprofessional behaviors: ______________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Essential behaviors: ___________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Most important attribute: _______________________________________________________________________________________
Professionalism post-test (if assigned by instructor). Attach score. ______________________________________________________
EXERCISE 1.3 Medical Director or Physician Interaction
Summarize the key points of the talk: ______________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
EXERCISE 1.4 Safety Considerations
E X E R C IS E 1. 4. 1 E LE C T R IC A L SAF ETY
Summarize policies: ___________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
2679_Ch01_001-016.indd 7 07/02/13 4:42 PM

E XE RCI SE 1 .4 .2 F IR E S A FE T Y
RACE: ______________________________________________________________________________________________________
PASS: ______________________________________________________________________________________________________
Nearest emergency exits: ______________________________________________________________________________________
Fire alarm: ___________________________________________________________________________________________________
Fire extinguisher: Location _______________________________________ Type _________________________________________
RT responsibilities: ____________________________________________________________________________________________
EXERCISE 1.4.3 OS H A S TA ND A R D S
OSHA regulation no.: _____________________________ Date of policy manual: _________________________________________
Prohibited activities: ___________________________________________________________________________________________
E XE RCI SE 1 .4 .4 H A Z A R D O U S M AT E R IA LS A N D MSDS SHEETS
Attach printout. _______________________________________________________________________________________________
Name of chemical: ____________________________________________________________________________________________
Health risk: __________________________________________________________________________________________________
Flammability: _________________________________________________________________________________________________
Reactivity: ___________________________________________________________________________________________________
PPE: _______________________________________________________________________________________________________
First aid procedures: ___________________________________________________________________________________________
Antidote (if any): ______________________________________________________________________________________________
EXERCISE 1.5 Scene Survey
E XE RCI SE 1 .5 .1 ID E NT IFIC AT IO N O F S A F E T Y HAZARDS—DIAGRAM
1. ___________________________________________________ 2. ___________________________________________________
3. ___________________________________________________ 4. ___________________________________________________
5. ___________________________________________________ 6. ___________________________________________________
7. ___________________________________________________ 8. ___________________________________________________
9. ___________________________________________________ 10. ___________________________________________________
E XE RCI SE 1 .5 .2 ID E NT IFIC AT IO N O F S A F E T Y HAZARDS—SCEN ARIO
1. Was the scene safe? List any hazardous conditions.
A. ____________________________________________________________________________________________________
B. ____________________________________________________________________________________________________
C. ____________________________________________________________________________________________________
D. ____________________________________________________________________________________________________
E. ____________________________________________________________________________________________________
F. ____________________________________________________________________________________________________
G. ____________________________________________________________________________________________________
2679_Ch01_001-016.indd 8 07/02/13 4:42 PM

H. ____________________________________________________________________________________________________
I. ____________________________________________________________________________________________________
J. ____________________________________________________________________________________________________
2. What equipment was seen in the immediate area? _______________________________________________________________
3. Were the conditions conducive to patient comfort? ______________________________________________________________
4. What were the environmental conditions like? Describe the temperature, humidity, lighting, and cleanliness. _________________
5. Were the patient’s material needs within easy reach? ____________________________________________________________
Critical Thinking Questions

1. Why is it necessary for hospitals to have special codes for fires, disasters, and cardiac arrests?
2. You are asked to enter a patient’s room to perform morning vital signs. When you approach the patient, you put the side
rail of the bed down to allow better access to the patient. There is an intravenous (IV) pump on the same side on which
you are standing. As you grab the IV pump to move it out of the way, you feel a mild tingling sensation in your hand.
A. What would be your next actions?
B. Why?
3. What would be the corrective actions for the following safety hazards?
A. Water on the floor
B. Patient found with side rails down
C. A patient who is using nasal oxygen being transported for an MRI
4. How many patient identifiers should be used before administering any treatment or drug to a patient?
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2679_Ch01_001-016.indd 10 07/02/13 4:42 PM
Procedural Competency Evaluation

STUDENT: DATE:
CLINICAL ORIENTATION
F Peer F Instructor F Lab F Clinical Simulation
PERFORMANCE LEVEL
PERFORMANCE RATING
Evaluator: Setting:
Equipment Utilized: Conditions (Describe):
Performance Level:
S or 3= Satisfactory, no errors of omission or commission
U = Unsatisfactory error of omission or commission
NA = Not applicable
Performance Rating:
5 Independent: Near-flawless performance; minimal errors; able to perform without supervision; seeks out new learning;
shows initiative; A = 4.7–5.0 average
4 Minimally Supervised: Few errors, able to self-correct; seeks guidance when appropriate; B = 3.7–4.65
3 Competent: Minimal required level; no critical errors; able to correct with coaching; meets expectations; safe; C = 3.0–3.65
2 Marginal: Below average; critical errors or problem areas noted; would benefit from remediation; D = 2.0–2.99
1 Dependent: Poor; unacceptable performance; unsafe; gross inaccuracies; potentially harmful; F = < 2.0
Two or more errors of commission or omission of mandatory or essential performance elements will terminate the proce-
dure, and require additional practice and/or remediation and reevaluation. Student is responsible for obtaining additional
evaluation forms as needed from the Director of Clinical Education (DCE).
STUDENT PREPARATION
1. Obtained health clearance
2. CPR certification verified
3. Completed OSHA bloodborne pathogen training
4. Completed HIPAA training
5. Completed any other training as required by the clinical site
6. Compliant with uniform dress code including: cleanliness of uniform, appropriate length of hair, and hand and fingernail hygiene
7. Has stethoscope and other appropriate equipment
8. Has received a clinical policy and procedure manual
9. Placed in a course appropriate clinical rotation
CLINICAL SITE
10. Introduced to Department Director and other appropriate clinical staff
11. Given a tour of the facility
12. Instructed on site-specific policies regarding: infection control, fire and safety, cell phone and beeper usage, and other policies
SIGNATURES Student: Evaluator: Date:
2679_Ch01_001-016.indd 11 07/02/13 4:42 PM

Clinical Performance Evaluation

PERFORMANCE RATING:
5 Independent: Near-flawless performance; minimal errors; able to perform without supervision; seeks out new learning; shows initiative;
A = 4.7–5.0 average
Circle the appropriate response below. Please be consistent, objective, and honest in your assessment of the student’s clinical
performance and ability.
PERFORMANCE CRITERIA SCORE

COGNITIVE DOMAIN
1. Consistently displays knowledge, comprehension, and command of essential concepts 5 4 3 2 1
2. Demonstrates the relationship between theory and clinical practice 5 4 3 2 1
3. Able to select, review, apply, analyze, synthesize, interpret, and evaluate information; makes recommendations to 5 4 3 2 1
modify care plan
PSYCHOMOTOR DOMAIN
4. Minimal errors, no critical errors; able to self-correct; performs all steps safely and accurately 5 4 3 2 1
5. Selects, assembles, and verifies proper function and cleanliness of equipment; ensures operation and corrects 5 4 3 2 1
malfunctions; provides adequate care and maintenance
6. Exhibits the required manual dexterity 5 4 3 2 1
7. Performs procedure in a reasonable time frame for clinical level 5 4 3 2 1
8. Applies and maintains aseptic technique and PPE as required 5 4 3 2 1
9. Maintains concise and accurate patient and clinical records 5 4 3 2 1
10. Reports promptly on patient status/needs to appropriate personnel 5 4 3 2 1
AFFECTIVE DOMAIN
11. Exhibits courteous and pleasant demeanor; shows consideration, respect, honesty, and integrity 5 4 3 2 1
12. Communicates clearly and concisely, both verbally and in writing 5 4 3 2 1
13. Preserves confidentiality and adheres to all policies 5 4 3 2 1
14. Follows directions, exhibits sound judgment, and seeks help when required 5 4 3 2 1
15. Demonstrates initiative, self-direction, responsibility, and accountability 5 4 3 2 1
TOTAL POINTS = /15 = AVERAGE GRADE =
ADDITIONAL COMMENTS: IDENTIFY AREAS OF EXCELLENCE; LIST ERRORS OF OMISSION OR COMMISSION, CRITICAL ERRORS
SUMMARY PERFORMANCE EVALUATION AND RECOMMENDATIONS

F PASS: Satisfactory performance
F Minimal supervision needed, may progress to next level provided specific skills, clinical time completed
F Minimal supervision needed, able to progress to next level without remediation
F FAIL: Unsatisfactory performance (check all that apply)
F Minor reevaluation only
F Needs additional clinical practice before reevaluation
F Needs additional laboratory practice before skills performed in clinical area
F Recommend clinical probation
SIGNATURES
Evaluator (print name): Evaluator Signature: Date:
Student Signature: Date:
Student Comments:
2679_Ch01_001-016.indd 12 07/02/13 4:42 PM


STUDENT: DATE:
PATIENT POSITIONING AND SAFETY

PERFORMANCE LEVEL
PERFORMANCE RATING
Evaluator: Setting:
Performance Level:
NA = Not applicable
Performance Rating:
EQUIPMENT AND PATIENT PREPARATION

1. Common Performance Elements Steps 1–8 (Refer to Appendix B)
2. Reads the medical record for any patient safety precautions identified: cardiac precautions, fall precautions, NPO, and/or fluid
restriction
3. Reads the medical record for any contraindication to position changes: postsurgical procedure orders, blood pressure precautions, and
other contraindications.
4. Observes the presence and location of any IV line, gastric tubes, or arterial lines that would need to be safeguarded during a position
change
5. Lowers side rail
6. Repositions patient into the desired position using assistance if required
7. Ensures the safety and integrity of any inserted lines
8. Observes/assesses for any changes in mental status, blood pressure, and pulse oximetry
9. Asks the patient (if able to respond) if any dizziness, nausea, or other complaints are present
10. Raises the side rail
11. Reaffirms patient comfort
FOLLOW-UP
2679_Ch01_001-016.indd 13 07/02/13 4:42 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch01_001-016.indd 14 07/02/13 4:42 PM


STUDENT: DATE:
PATIENT AND CAREGIVER TRAINING

PERFORMANCE LEVEL
PERFORMANCE RATING
Evaluator: Setting:
Performance Level:
NA = Not applicable
Performance Rating:

ASSESSMENT AND IMPLEMENTATION

2. Common Performance Elements Steps 9 and 10 (Refer to Appendix B)
3. Assesses the patient and/or family members for limitations to training
A. Language, literacy, or cultural barriers
B. Motivation and cooperation
C. Physical impairment (e.g., hypoxia, decreased sensorium, hearing, vision, energy, age-specific restriction or impairment, pain,
medication side effects)
D. Psychosocial barriers (e.g., anxiety, depression, substance abuse)
4. Determines gap between current knowledge and educational goals
5. Interviews patient or caregiver regarding past experience with topic being taught
6. Observes patient’s or caregiver’s performance of skills and determines whether they are adequate for self-care
7. Arranges convenient time for patient, family, caregiver, and practitioner
8. Arranges location for training conducive to learning
9. Prepares/obtains lesson plan and instructional materials
10. Limits interruptions, distractions, and noise
11. Conducts educational session using terminology appropriate to audience
12. Monitors patient or caregiver during training session including verbal and nonverbal responses
13. Evaluates outcomes by appropriate methods including:
A Demonstration of skills
B. Verbal, nonthreatening questioning
C. Requests patient or caregiver to repeat information in own words
14. Answers patient or caregiver questions using terminology appropriate to audience
FOLLOW-UP
16. Documents competencies achieved
2679_Ch01_001-016.indd 15 07/02/13 4:42 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
3. Able to select, review, apply, analyze, synthesize, interpret, and evaluate information; makes recommendations 5 4 3 2 1
to modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch01_001-016.indd 16 07/02/13 4:42 PM

Communication
CHAPTER
and Cultural
Diversity in
Health Care
INTRODUCTION Oral and written communication are key skills required by all health-care practitioners.
This chapter will address oral communication skills; Chapter 5 will address written
skills. The respiratory care practitioner (RCP) must communicate orally on several
levels. The first level is peer communication, and peers include nurses, fellow RCPs,
and other members of the health-care team. The second level is communication with
physicians and supervisors. The third and most important level is communication with
the patient. While the communication should be clear, empathetic, and therapeutic,
the practitioner must also be able to communicate with patients of all ages. This
age-specific communication competency requires practice. Therefore, each level of
communication requires a different approach and skill. Many factors influence
communication in the health-care setting (Table 2.1).
In addition, careful attention must be paid to the cultural and religious needs of the
patient. This requires cultivating sensitivity to the cultural diversity of the population.
Language barriers, inappropriate use of translators, and lack of time frequently are
misinterpreted as bias, prejudice, or disrespect.
OBJECTIVES 1. Relate factors that influence communication.

Upon completion of this 2. Discuss the impact of culture on health-care delivery.
3. Use therapeutic communication skills to establish patient rapport.
KEY TERMS
communication empathetic sensitivity
cultural diversity empathy sympathy
Exercises
None
17
2679_Ch02_017-020.indd 17 08/02/13 4:51 PM

Table 2.1 Factors Influencing
Internal Factors Sensory/ Environmental Verbal Nonverbal
Communication
Emotional Factors Expression Expression
Factors
Clinician Previous experiences Stress Lighting Jargon Body language
Attitudes, values Workload Noise Technical Facial expressions
Cultural heritage Non–work-related Privacy language Dress
Religion issues Distance Voice tone Professionalism
Self-concept Warmth
Listening habits Interest
Preoccupation
Feelings
Age
Patient Previous experiences Fear Lighting Language barrier Body language
Attitudes, values Pain Noise Jargon Facial
Cultural heritage Anxiety Privacy Voice tone expressions
Religion Stress Distance
Self-concept Mental acuity Temperature
Listening habits Brain injury
Preoccupation Hypoxia
Feelings Sense impairment
Illness
Age
Adapted from Wilkins, RL, Sheldon, RL, and Krider, SJ: Clinical Assessment in Respiratory Care, ed. 2, Mosby-Year
Book, St. Louis, 1990.
EXERCISE 2.1 COMMUNICATION
Discuss with your laboratory partner any experiences each of you may have had as patients in a
hospital or other setting. Describe your feelings in this situation. Include in your discussion atti-
tudes toward health care that are culturally based. Do you feel that the quality of your care was
affected by cultural, ethnic, or racial issues? If you and your partner have never had these experi-
ences, describe what concerns would be most important in the event that one of you was hospi-
talized. Be prepared to share your experiences with the class.
EXERCISE 2.2 CULTURAL DIVERSITY

EXERCISE 2.2.1 CULTUR E-R EL ATED H E A LT H -C A R E B E LI E FS
Your instructor will divide the class into diverse pairs. Ask your partner to name the cultural
group with which your partner identifies and list five cultural influences that have an effect on
your partner’s beliefs. These may be related to diet, religious practice, or family influences.
Record the beliefs on your laboratory report. Share your culture-related health-care beliefs
with the class. Compare the similarities and contrast the differences of your partner’s beliefs.
EXERCISE 2 .2.2 CULTUR AL C ASE S T U D Y

Scenario
Read the following scenario Mr. Rodriguez is a 70-year-old Mexican man who recently arrived in the United States and
and critique how the case does not speak English. He is brought to the emergency department (ED) by his 13-year-old
was handled. What could granddaughter. The nurse asks him why he is in the ED. He begins to explain in Spanish, but the
the caregivers have done to nurse cuts him off and starts quizzing the girl. Mr. Rodriguez begins to get agitated at the nurse,
be more culturally aware and screams aloud, and clutches his chest. The nurse asks the young girl to leave and shouts at
sensitive to the patient’s Mr. Rodriguez to shut up. The physician’s assistant, who has been in the room the entire time,
needs? begins to take vital signs and start an IV in silence. Mr. Rodriguez is still agitated but takes out
a religious prayer card and begins praying. The nurse confiscates the card, muttering that this is
not the appropriate place for personal property to be kept.
2679_Ch02_017-020.indd 18 08/02/13 4:51 PM

C H A P T E R 2 | C O M M U N I C AT I O N A N D C U LT U R A L D I V E R SITY IN HEALTH C AR E • 19
Laboratory Report
CHAPTER 2: COMMUNICATION AND CULTURAL DIVERSITY IN HEALTH CARE
Name: Date:
Data Collection
EXERCISE 2.1 Communication
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
EXERCISE 2.2 Cultural Diversity
E X E R C IS E 2. 2. 1 C U LT U R E -R E L ATED HEALTH-CARE BEL IEF S
Cultural or ethnic group:
Culture-related health-care beliefs:
1.
2.
3.
4.
5.

1. How might differences in cultural or ethnic background between the practitioner and the patient affect the
practitioner’s ability to perform a patient assessment?
2. How might a respiratory care practitioner better prepare for and understand the cultural needs of the patient when
providing care?
3. How does religion impact one’s health? How can the respiratory care practitioner accommodate a patient’s religious
beliefs?
2679_Ch02_017-020.indd 19 08/02/13 4:51 PM

2679_Ch02_017-020.indd 20 08/02/13 4:51 PM
CHAPTER Infection Control
INTRODUCTION For centuries, infectious diseases have been the major cause of death in humans. Until
recently, the scientific community believed that advances in the development of vaccines
and antibiotic therapy would eliminate many infectious diseases by the 21st century.
However, misuse and overuse of antibiotics, lax attitudes regarding the application of
these advances, and the remarkable ability of microorganisms to adapt are threatening
much of the progress made in the fight against infection. As a result, we now find
ourselves faced with a resurgence of diseases that were thought to be no longer a
problem, including tuberculosis, measles, cholera, and typhoid.
Resistant strains of microorganisms and the discovery of new infectious diseases such as
SARS and H5-N1 influenza are appearing in epidemic proportions. All are challenging our
medical technology and altering the way health care is delivered.
The combination of a susceptible host, invasive procedures providing a route of

transmission, and the presence of virulent and antibiotic-resistant strains of microbial
organisms makes health-care settings the perfect location for the transmission of
infectious disease.
Recent concerns center around the protection of health-care workers from bloodborne
pathogens, which include but are not limited to hepatitis B virus, HIV, and related
transmissible illnesses such as tuberculosis.1
Infection control in the health-care setting has two primary goals. The first goal is to
protect health-care workers from transmissible diseases. The second goal is to reduce the
incidence of nosocomial infections in susceptible patients. All health-care personnel must
maintain up-to-date knowledge and compliance with most current guidelines.
We can reduce the risks to health-care workers and patients by four methods.2,3
1. Providing barriers to transmission. This includes understanding the routes of

transmission and applying standard precautions and transmission-based isolation
procedures to prevent transmission.
2. Eliminating sources of infectious agents. This includes decontamination, disinfection,
and sterilization of equipment; proper disposal of infectious waste; and, most
importantly, hand washing or hand sanitation before and after patient contact,
attending to any personal hygiene activities, and proper handling of dirty and clean
equipment.
3. Assessing host susceptibility. This includes factors related to the patient’s preexisting
medical conditions (such as diabetes), immune status, reducing exposure to sources
of infection, appropriate use of antimicrobial agents, and limiting invasive procedures
to only those that are essential.
4. Monitoring and evaluating the effectiveness of infection control procedures. This
includes epidemiological surveillance and quality management procedures.
21
2679_Ch03_021-040.indd 21 07/02/13 4:42 PM

OBJECTIVES 1. Demonstrate effective hand washing and hand sanitation technique.

Upon completion of this 2. Demonstrate a 3-minute surgical scrub.
3. Apply standard precautions and transmission-based isolation procedures according to Centers
for Disease Control and Prevention (CDC) guidelines.
4. Distinguish among various types of isolation procedures and apply applicable precautions for
each.
5. Practice procedures mandated by the Occupational Safety and Health Administration (OSHA)
for the handling and disposal of infectious waste or equipment.
KEY TERMS
AFB endemic immunology phagocytosis
aerobe endocytosis immunosuppression prokaryotic
anaerobe endotoxin infection proliferation
antiseptic enteric inhibition prophylactic
asepsis epidemic morphology prophylaxis
bacteremia eukaryotic mutualism pus
bactericidal exotoxin mycology sepsis
bacteriostatic facilitate necrosis septicemia
cell mediated facultative nosocomial symbiosis
colonization fastidious obligate synergism
commensalism fomite opportunistic vector
condensate hemolytic optimum virology
debilitated homogeneous parasitism virulence
desiccation humoral pathogen virulent
Exercises
E Q U I PM E N T R E Q U IR E D
F Antimicrobial liquid soap in dispenser F Isolation head and foot coverings
F Bar soap F Paper towels
F Disposable high-efficiency particulate aerosol F Protective eyewear or face shields
(HEPA) filter masks F Sample isolation signs
F Disposable isolation gowns F Sink with running water
F Disposable nitrile and vinyl gloves in various F Sterile gloves in various sizes
sizes F Stopwatch
F Hand sanitizing solution (liquid or foam) and F Surgical masks
dispenser
F Surgical scrub brushes
2679_Ch03_021-040.indd 22 07/02/13 4:42 PM

C H A P T E R 3 | INFEC TION C ONTR OL • 23
EXERCISE 3.1 HAND WASHING
Proper hand washing before 1. Remove jewelry and watch.

and after any patient contact 2. Adjust water flow and temperature using pedals, if available, as shown in Figure 3.1, or
is one of the most important hand faucet controls.
infection control procedures. 3. Wet forearms and hands.
4. Apply disinfectant liquid soap liberally.
5. Wash with strong friction for as long as you feel appropriate. Have your partner use a
stopwatch to time how long you wash. Record the initial time on your laboratory report.
6. You should scrub the following as shown in Figure 3.2:
A. Palms
B. Between digits
C. Under fingernails and around cuticles with a brush
D. Wrists and forearms
NOTE: Make sure you do not touch the sink with your hands or body.
7. Wash your hands for a minimum of 15 seconds.3 If you did not achieve this time initially,
repeat step 5. Sing a chorus of Yankee Doodle or My Country ’Tis of Thee to get the timing
down.
8. Rinse from the forearm to the fingertips, ensuring that all soap solution has been removed.
9. Obtain paper towels aseptically.
10. Dry hands individually, using separate towels.
11. Turn off water faucets using a dry, clean towel if pedals are not available.
12. Discard paper towels in an appropriate waste container.
1. Wet 2. Soap
3. Wash for 20 seconds 4. Brush fingers

and nails
5. Dry 6. Turn off faucet

Figure 3.1. Adjusting water flow using foot pedal. Figure 3.2. Hand washing technique.
2679_Ch03_021-040.indd 23 07/02/13 4:42 PM

EXERCISE 3.2 HAND SANITATION
1. Remove jewelry and watch.

2. Fill your palm with liquid or foam sanitizing hand solution.
3. Rub into your hands, between fingers, and into palms and wrists for at least 10 seconds until
dry.
4. Look up the recommendations for how often hand sanitizing lotion can be applied before
hand washing is required. Record this information on your laboratory report.
EXERCISE 3.3 SURGICAL SCRUB
1. Obtain a package of surgical scrub brush with soap.

2. Remove jewelry and watch.
3. Adjust water flow and temperature using foot pedals. Wet forearms and hands.
4. Open scrub package and begin scrubbing hands and arms up to your elbow for at least 3
minutes.
5. Rinse from elbows toward fingertips, ensuring that all soap solution has been removed.
6. Obtain paper towels aseptically.
7. Dry hands individually, using separate towels.
8. Turn off water faucets using a dry, clean towel if foot pedals are not available.
9. Discard paper towels in an appropriate waste container.
EXERCISE 3.4 BARRIER PRECAUTIONS/PERSONAL PROTECTIVE EQUIPMENT

EXERCISE 3 .4 .1 S TAN DARD P R ECAU T I O N S / T R A N S MI S S I O N -B A S E D I S O LAT I O N
P R OCEDUR ES
Protecting our patients and 1. Review all signs and posters for standard precautions and transmission-based isolation
ourselves against infection procedures as illustrated in Figures 3.4 to 3.7.
requires strict adherence to 2. Review all category-specific isolation precautions4 as shown in Table 3.1. The CDC classifies
current infection control four categories for isolation procedures: standard, airborne, droplet, and contact precautions.
procedures.1,4 To create Standard precautions synthesize the major features of universal (blood and body fluid
barriers to transmission, precautions) and body substance isolation.5 Transmission-based precautions are designed for
one must be aware of the patients documented or suspected to be infected with highly transmissible or
routes of transmission of epidemiologically important pathogens for which additional precautions are needed to
infectious disease (Fig. 3.3). interrupt transmission.4 Airborne precautions are designed to reduce the risk of transmission
of infectious agents by droplet nuclei or dust particles. Droplet precautions reduce the
transmission of infectious agents through large droplet contact (greater than 5µ such as
occurs with coughing, sneezing, or talking. Immunocompromised patients, such as those with
cancer, leukemia, severe burns, or organ transplants, are generally at increased risk for
bacterial, fungal, parasitic, and viral infections from both endogenous and exogenous
sources.5 The use of standard precautions for all patients and transmission-based precautions
for specified patients should reduce these patients’ acquisition of nosocomial infections.
2679_Ch03_021-040.indd 24 07/02/13 4:43 PM

Eye Respiratory
droplets
Nose
Mouth (water or food)
Bites of
vectors
Blood
Skin (breaks) Skin contact
Urinary or Feces
Figure 3.3. Routes of transmission reproductive Reproductive
Urine tract
of infectious diseases. tracts
Figure 3.4. Standard precautions.

(Courtesy of Brevis Corp., Salt Lake
City, Utah.)
2679_Ch03_021-040.indd 25 07/02/13 4:43 PM

Figure 3.5. Transmission-based

precautions: Contact precautions.
City, UT.)
2679_Ch03_021-040.indd 26 07/02/13 4:43 PM


precautions: Droplet precautions.
City, UT.)
2679_Ch03_021-040.indd 27 07/02/13 4:43 PM


precautions: Airborne precautions.
City, UT.)
2679_Ch03_021-040.indd 28 07/02/13 4:43 PM

Table 3.1 Isolation Precautions
CATEGORY REQUIREMENTS SELECTED INDICATIONS
Standard Hand washing with nonanti- Routine; before and after all patient contact
microbial soap
Hand washing with antimicro- For specific outbreaks as defined by infection control program
bial soap
Gloves When touching blood, body fluids, secretions, mucous mem-
branes, nonintact skin
Mask, eye protection, face For procedures likely to generate splashes or sprays of blood,
shield body fluids, secretions, and excretions
Gown For procedures and activities that are likely to generate sprays or
splashes or cause soiling
Patient-care equipment To prevent skin and mucous membrane exposures and contami-
nation of clothing; clean and reprocess reusable equipment be-
tween patients; discard single-use items
Environmental control Routine care: cleaning and disinfection of environmental sur-
faces, beds, bedrails, bedside equipment; blood spills should be
cleaned up promptly with 5.25% solution of sodium hypochlorite
diluted 1:10 with water
Linen Handle, transport, and process used linen soiled with blood, body
fluids, secretions, and excretions to prevent skin and mucous
membrane exposures, contamination of clothing and avoid trans-
fer of microorganisms to other patients and environments
Occupational health and Prevent injuries when using, cleaning, or disposing of needles,
bloodborne pathogens scalpels, and other sharps; do not bend, break, or otherwise ma-
nipulate by hand; never recap using any technique involving point
of sharp toward any part of the body
Private room For patient who contaminates the environment or who cannot as-
sist in maintaining hygiene or environmental control
Airborne In addition to standard Patients known or suspected to be infected with organisms trans-
precautions: mask mitted by airborne droplet nuclei; measles (rubeola); chicken pox
Private room with door closed varicella; tuberculosis
and monitored negative air
pressure; 6 to 12 air changes
per hour; discharge of air
outdoors or monitored HEPA
filtration of room air
Respiratory protection
Limit patient transport, mask
patient
Droplet In addition to standard Known or suspected to be infected with microorganisms
precautions: mask transmitted by large particle droplet (>5 ␮) that can be generated
Private room during coughing, sneezing, talking, or performance of procedures
Mask when working within 3 Invasive Haemophilus influenzae–type disease including
feet of patient meningitis, pneumonia, epiglottitis, and sepsis; invasive Neisseria
meningitidis disease including meningitis, pneumonia and sepsis;
Limit patient transport, mask
diphtheria, Mycoplasma pneumoniae, pertussis, pneumonic
patient
plague, streptococcal pharyngitis, pneumonia, or scarlet fever in
infants and young children; adenovirus, influenza, mumps rubella
Contact In addition to standard Gastrointestinal, respiratory, skin and wound, or colonization by
precautions: gown multidrug-resistant bacterial infections such as methicillin-
Private room resistant Staphylococcus aureus (MRSA)
Masks Enteric infections with low infectious dose including Clostridium
difficile; infectious diarrhea from Escherichia coli, Shigella,
Gloves when entering room;
hepatitis A, or rotavirus
change when soiled and
before leaving room Respiratory syncytial virus, parainfluenza virus, or enteroviral
infections in infants and young children
Gowns when entering room if
soiling likely; change after Skin infections that are highly contagious including diphtheria
contact with infective material (cutaneous), herpes simplex virus, impetigo, major abscesses,
cellulitis or decubiti, pediculosis, scabies; herpes zoster; viral
hemorrhagic conjunctivitis; viral hemorrhagic infections including
Ebola, Lassa, and Marburg virus
*Note: Hands must be washed after touching patient or potentially contaminated articles for all categories.
Contaminated articles should be discarded or bagged and labeled.
2679_Ch03_021-040.indd 29 07/02/13 4:43 PM

3. Obtain all personal protective equipment (PPE) required for standard transmission–based
isolation procedures. Wash your hands before this procedure. Apply the equipment in the
following order3 (Fig. 3.8):
A. Hair and foot coverings. Make sure all of your hair is covered.
B. Gown.
i. Open gown fully.
ii. With the opening in the back, insert your arms into the sleeves.
iii. Fasten ties at the neck and waist.
C. Mask. Make sure that both your nose and mouth are completely covered and the mask
is tied to the back of the head or straps are adjusted. You should change your surgical
mask frequently because it is ineffective once it becomes wet.
D. Goggles or face shield. Although goggles or a face shield are not part of required strict
isolation equipment, they may be necessary if you anticipate splashing of blood or body
fluids.
E. Gloves. Gloves should fit well. Examine for any tears or holes and replace if necessary.
You may substitute nitrile powder-free or vinyl gloves if latex sensitivity or powdered
gloves are a problem.
4. Remove all PPE in the following sequence:
A. Head and foot coverings.
B. Mask and goggles.
C. Gloves. Remove gloves by pulling down from the wrist and turning them inside out.
D. Gown. After untying neck and waist, remove gown inside out.
5. Discard disposable items in infectious waste container. (For purposes of laboratory practice,
PPE may be saved to reuse in later exercises.)
6. Wash your hands.
Figure 3.8. Personal protective equipment (PPE).
2679_Ch03_021-040.indd 30 07/02/13 4:43 PM

EXER C ISE 3.4.2 AP P LIC AT I O N O F S T E R I LE G LO V E S

When applying sterile gloves, it is important to follow the proper sequence of steps to prevent
contamination, as shown in Figure 3.9.
A B
C D
E
Figure 3.9. Application of sterile gloves. (Adapted from Frew, MA, Lane, K and Frew, DR: Comprehensive Medical Assisting, ed. 3.
FA Davis, Philadelphia, 1995, pp. 615–617, with permission.).
2679_Ch03_021-040.indd 31 07/02/13 4:43 PM

During this exercise you will 1. Obtain the proper size package of sterile gloves.
be placing a glove on your 2. Wash your hands.
dominant hand first, using 3. Open package aseptically and unfold it completely, making sure both gloves are accessible.
the opposite (nondominant) Do not touch the inside of the package (Fig. 3.9A).
hand to handle the glove. If 4. Using your nondominant hand, pick up the cuffed (folded) portion of the glove that will be
you are right handed, your pulled onto your dominant hand. Make sure not to touch any part of the glove other than
right hand is your dominant the outside of the folded portion of the cuff (Fig. 3.9B).
hand and your left hand is 5. Slide your dominant hand into the glove as far as possible. Now raise your hand and apply
your nondominant hand. If the glove completely. Use your nondominant hand to pull the glove on while touching only
you are left handed, the the inside of the glove (Fig. 3.9C).
opposite is true. 6. Using your gloved dominant hand, pick up the other glove, using two or three fingers
inserted into the cuffed portion (Fig. 3.9D).
7. Slide your ungloved nondominant hand into the glove as far as possible. Now raise your
hand and apply the glove completely. Do not touch your skin with the sterile gloved hand.
Pull the glove on by the cuff while touching only the outside of the glove (Fig. 3.9E).
8. Remove gloves. Gloves should be removed by pulling them down from the wrist and turning
them inside out.
9. Discard gloves in an infectious waste container.
EXERCISE 3 .4.3 AIRBORN E/DR OPL ET P R E C A U T I O N S

OSHA regulations for 1. Obtain a disposable HEPA filter mask. Read the directions on the manufacturer’s label.
tuberculosis precautions now 2. Apply the mask according to the manufacturer’s directions, as shown in Figure 3.10. Make
require the use of a high- sure the mask fits well.
efficiency particulate aerosol
NOTE: Facial hair may interfere with the effective functioning of this mask. Also, health-care
(HEPA) mask as part of PPE,
providers may need medical clearance to wear these types of masks for any length of time. Preex-
or other similar devices
isting pulmonary disease or reduced flow rates may cause difficulty in breathing through these
recommended by the
masks. Your medical director should be consulted regarding guidelines.
National Institute for
Occupational Safety and 3. Leave the mask on for 5 minutes, as tolerated. Record your observations on your laboratory
Health (NIOSH).4,6 NIOSH report.
certifies three types of
masks as acceptable:
HEPA 100, with a 99.97%
efficiency rate; HEPA 99,
with a 99% efficiency rate;
and HEPA 95, with a 95%
efficiency rate. OSHA relies
on NIOSH certification for
its recommendations.
Review the current CDC
recommendations for
respiratory/tuberculosis
isolation precautions.
2679_Ch03_021-040.indd 32 07/02/13 4:43 PM

Figure 3.10. Application of high-efficiency particulate aerosol (HEPA) filter mask.

(Courtesy of 3M Occupational Health and Environmental Safety Division, St. Paul, MN.)
R E FE R E N C E S
1. Occupational Safety & Health Administration: Bloodborne pathogens. Available at: www.osha.gov/pls/oshaweb/owadisp.show_
document?p_table=standards&p_id=10051.
2. Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases: Vectorborne and enteric
diseases. Available at: http://www.cdc.gov/oid/framework.html.
3. Centers for Disease Control and Prevention: Hand hygiene in health-care settings. Available at: www.cdc.gov/handhygiene/Guidelines.html.
4. Centers for Disease Control and Prevention: 2007 guideline for isolation precautions: Preventing transmission of infectious agents in health-
care settings. Available at: www.cdc.gov/hicpac/2007IP/2007isolationPrecautions.html.
5. Centers for Disease Control and Prevention: Infection control in health-care settings. Available at: www.cdc.gov/tb/topic/infectioncontrol/
default.htm.
2679_Ch03_021-040.indd 33 07/02/13 4:43 PM

2679_Ch03_021-040.indd 34 07/02/13 4:43 PM
Laboratory Report
CHAPTER 3: INFECTION CONTROL
Name: Date:
Data Collection
EXERCISE 3.1 Hand Washing
Time of initial hand washing in seconds: ___________________________________________________________________________
EXERCISE 3.2 Hand Sanitation
Application of hand sanitizing lotion information: _____________________________________________________________________
EXERCISE 3.4 Barrier Precautions/PPE
E X E R C IS E 3. 4. 3 A IR B O R N E /D ROPL ET PRECAUTION S
Observations wearing HEPA filter mask: ____________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

1. Mr. Abraham is a 40-year-old man mechanically ventilated with an oral endotracheal tube in place. You note on his
chart that a methicillin-resistant form of Staphylococcus aureus (MRSA) has been cultured from his sputum.
A. What types of transmission-based isolation precautions should you take before entering the room?
B. List the PPE required.
C. What type of antimicrobial therapy would be recommended to treat this patient’s infection?
2679_Ch03_021-040.indd 35 07/02/13 4:43 PM

2. Ms. Holland is a 27-year-old woman who is HIV positive. She was admitted with respiratory difficulty. Sputum analy-
sis has proved positive for acid-fast bacillus.
A. What types of transmission-based isolation precautions are indicated in this patient?
B. Describe what infection control precautions (relating to the equipment, the patient, and yourself) should you use
when performing an arterial blood gas on this patient.
C. You inadvertently spill some blood on the floor while performing the arterial blood gas on this patient. What
action or actions should be taken to clean up the spill? Specify the solution used.
2679_Ch03_021-040.indd 36 07/02/13 4:43 PM


STUDENT: DATE:
HAND HYGIENE
PERFORMANCE LEVEL
PERFORMANCE RATING
Evaluator: Setting:
Performance Level:
NA = Not applicable
Performance Rating:
HAND WASHING WITH SOAP AND WATER

1. Removes personal articles
2. Adjusts water flow and temperature; avoids contact with sink
3. Wets forearms and hands thoroughly
4. Applies disinfectant soap liberally
5. Washes hands with appropriate friction for a minimum of 15 seconds
A. Palms
B. Wrists
C. Between fingers
D. Nails/cuticles
E. Forearms
6. Washes for appropriate length of time (repeats when indicated)
7. Avoids hand/finger contact with fixtures
8. Rinses thoroughly from the forearm to the fingertips
9. Obtains paper towels without contamination
10. Dries areas thoroughly
11. Turns off water avoiding recontamination
12. Maintains and processes equipment; disposes of infectious waste
HAND DISINFECTION WITH ALCOHOL-BASED DISINFECTANT

13. Removes personal articles
14. Inspects hands to ensure that they are not soiled
15. Applies gel to the palm of one hand
16. Rubs hands together, covering all surfaces of the hands and fingers
17. Continues to rub until all surfaces are dry
2679_Ch03_021-040.indd 37 07/02/13 4:43 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch03_021-040.indd 38 07/02/13 4:43 PM


STUDENT: DATE:
PATIENT STANDARD PRECAUTIONS/TRANSMISSION-BASED ISOLATION PROCEDURES

PERFORMANCE LEVEL
PERFORMANCE RATING
Evaluator: Setting:
Performance Level:
NA = Not applicable
Performance Rating:


2. Removes jewelry and watch
3. Adjusts water flow and temperature
4. Wets forearms and hands; applies disinfectant soap liberally
5. Washes hands for a minimum of 15 seconds with strong friction; washes palms, between the digits, under fingernails, and around
cuticles
A. Never touches sink with hands
6. Rinses from forearm to fingertips
7. Obtains towels aseptically and dries hands using individual towels
8. Turns off water using dry, clean towel
9. Reviews patient chart and surveys room for any posted transmission-based precautions
10. Obtains and applies appropriate PPE in the proper sequence: hair and foot coverings, gown, mask, goggles and/or face shield, and
gloves
11. Performs procedure
FOLLOW-UP
12. Bags, seals, and labels any contaminated equipment
13. Removes PPE in proper sequence
14. Disposes of any infectious waste
15. Washes hands
16. Transports contaminated equipment in low-traffic areas
2679_Ch03_021-040.indd 39 07/02/13 4:43 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch03_021-040.indd 40 07/02/13 4:43 PM

CHAPTER Sterilization and
Disinfection
INTRODUCTION As discussed in the previous chapter, the second component of good infection control is
the prevention of nosocomial infections. An essential component is the disinfection and
sterilization of equipment. While the majority of today’s respiratory care equipment is
single-patient use and disposable, rising costs of equipment and its disposal are making
respiratory care departments rethink the use of permanent, nondisposable equipment.
There are several methods used for the sterilization and disinfection of respiratory care
equipment. The first step is decontamination, which removes the infectious, organic
residues from the equipment. Sterilization is the killing of all microorganisms. The
process of sterilization may be physical (steam autoclave) or chemical (ethylene oxide).
Disinfection, which usually is not effective against spores, can be achieved by
pasteurization. Many respiratory care departments have instituted batch pasteurization
as a way of holding down the rising costs of disposable supplies such as tubing. “Cold
sterilization” with activated glutaraldehyde is a high-level disinfection, rather than
sterilization, method due to the impossibility of preventing exposure during the rinse
phase prior to packaging.
Respiratory care practitioners (RCPs), as part of the health-care team, should be

intimately familiar with issues concerning the etiology and epidemiology of infectious
disorders. Each RCP must adhere to established guidelines. Knowledgeable RCPs can
serve as positive role models and educators to reinforce the importance of every health-
care provider’s responsibility in preventing and controlling infection.
OBJECTIVES 1. Differentiate among the methods for decontamination, disinfection, and sterilization.
Upon completion of this 2. Prepare equipment for the most commonly used methods of decontamination, disinfection,
chapter, you will be able to: and sterilization.
3. Practice monitoring techniques for evaluating the effectiveness of infection control procedures.
4. Practice communication skills needed to explain infection control procedures to patients.
5. Practice documentation of infection control procedures.
KEY TERMS
aseptic disinfectant etiology sterilization
autoclave disinfection glutaraldehyde thermophilic
decontamination epidemiology pasteurization
41
2679_Ch04_041-050.indd 41 07/02/13 4:43 PM

Exercises
F Agar plates F Infectious waste bags with biohazard labels
F Antimicrobial liquid soap in dispenser F Isolation head and foot coverings
F Aseptic area/field for drying equipment F Paper towels
F Bar soap F Protective eyewear or face shields
F Biological indicator vials F Sample syringes, “contaminated” equipment,
F Chemical indicator tape and waste
F Culture swabs F Sharps containers
F Detergent solution F Sink with running water
F Disposable high-efficiency particulate aerosol F Surgical masks
(HEPA) filter masks F Various bags and wraps for equipment
F Disposable isolation gowns packaging
F Disposable latex and vinyl gloves in various F Various size equipment brushes
sizes
EXERCISE 4.1 HANDLING AND DISPOSAL OF INFECTIOUS EQUIPMENT AND WASTE
In this exercise, you are 1. Wash your hands as previously instructed.

simulating entering the room 2. Apply the required PPE for contact isolation.
of a patient in contact 3. Enter the “patient’s room.”
isolation to discard 4. Carefully dispose of any sharps (needles, syringes, lancets) into the puncture-proof sharps
disposable infectious waste container (Fig. 4.1). If the container is full, replace it with a new one.
and safely remove a piece of 5. Obtain infectious waste bags labeled with a biohazard indicator.
reusable respiratory 6. Place the reusable equipment into the infectious waste bag, secure it, and label it as in
equipment for transport to Figure 4.2. Be careful not to contaminate the outside of the bag.
the disinfection area. The 7. Leave the “room.” Remove your PPE in the sequence previously described, and discard it in
instructor will have the an infectious waste container.
“room” prepared with
equipment to be discarded
and to be transported.
Figure 4.1. Puncture-proof sharps container

with biohazard symbol.
2679_Ch04_041-050.indd 42 07/02/13 4:43 PM

C H A P T E R 4 | S T E R I LI Z AT I O N AND DIS INFEC TION • 43
Figure 4.2. Bagging of contaminated equipment. A B
EXERCISE 4.2 PREPARATION OF EQUIPMENT FOR DISINFECTION/STERILIZATION BY

AUTOCLAVE, ETHYLENE OXIDE, ACTIVATED GLUTARALDEHYDE, OR PASTEURIZATION
The instructor will provide 1. Put on PPE, including gloves and gown.
nondisposable equipment for 2. Completely disassemble the equipment into its smallest parts.
this exercise. Although 3. Examine the equipment for any tears, cracks, or pitting. Discard defective equipment because
specific requirements vary the defects can provide a safe hiding place for microorganisms.
with the method of 4. Soak the equipment for at least 10 minutes in a warm solution of disinfecting detergent
disinfection or sterilization to agent.
be used, there are steps in 5. Scrub the equipment parts thoroughly, making sure to get into any crevices and bends
equipment preparation (Fig. 4.3).
common to all modalities. 6. Rinse the equipment thoroughly with tap water.
Not all schools have the 7. Set the equipment out to dry on aseptic absorbent disposable towels provided for this
facilities to conduct all parts purpose.
of this exercise. If access to 8. Reassemble the equipment. Loosely secure any parts so that the disinfection/sterilization
disinfection/sterilization method can penetrate.
equipment and areas is 9. Once the equipment is reassembled, it is ready for the appropriate sterilization method:
available, you should A. For autoclave or gas sterilization with ethylene oxide, the equipment is first packaged in
perform all elements. If not, the appropriate materials; sealed; labeled with time, date, load, and technician signature;
you should perform steps 1 and marked with chemical indicator tape (Fig. 4.4). The equipment is then sterilized
through 8 and then examine and aerated, if necessary. Any required paperwork should be completed according to
the materials necessary for institution policy.
the remaining steps. In the B. For cold sterilization with glutaraldehyde, wear your protective eyewear. Soak the
absence of such equipment, equipment in the disinfecting solution for 10 minutes to 10 hours, depending on
an alternative to this whether disinfection or sterilization is to be achieved. When it is ready, put on sterile
exercise is a tour or rotation gloves and prepare a sterile field. Rinse the equipment aseptically with sterile water, dry
through the sterilization/ it on the sterile field, and package for storage. Label the package with the date, time,
disinfection department at and your signature. Complete any required paperwork according to institution policy.
a clinical agency. C. For pasteurization, load the equipment into the machine and run through the cycle.
Then dry and package the equipment for storage. Label the package with the date, time,
and your signature. Complete any required paperwork according to institution policy.
Figure 4.3. Scrubbing equipment.
2679_Ch04_041-050.indd 43 07/02/13 4:43 PM

exp. 11/2016
Lot - 1234
Figure 4.4. Packaging of equipment for sterilization.
EXERCISE 4.3 MONITORING INFECTION CONTROL PROCEDURES
Monitoring of infection control techniques is essential in evaluating their effectiveness. You can
use a variety of microbial culture techniques, depending on the item to be cultured.
Not all schools have the facilities to conduct all parts of this exercise. If access to a microbiology
laboratory is available, you should perform all elements.
EXERCISE 4 .3 .1 BIOL OGICAL MON IT O R S

Examine the biological monitor vials or strips used for autoclave and ethylene oxide sterilization
(Fig. 4.5).
Figure 4.5. Biological indicator.
2679_Ch04_041-050.indd 44 07/02/13 4:43 PM

C H A P T E R 4 | S T E R I LI Z AT I ON AND DIS INFEC TION • 45
EXER C ISE 4.3.2 SWAB CU LT U R I N G

Swab culturing may be used 1. Wash your hands thoroughly.
to take spot cultures of 2. Obtain the sterile swabs and culture medium tubes.
various surfaces, such as 3. Using separate culture swabs and tubes, culture each of the following:
tracheostomy stoma sites A. The palms of your hands
(Fig. 4.6). B. The drain area of the sink
C. Bar soap
4. Rub the swab back and forth over the area to be cultured. Aseptically replace the swab in
the culture tube.
5. Seal the culture tube. Label it with the date, time, and area cultured.
6. Send the culture tube to the microbiology laboratory for culturing and identification.
7. When results are available, record them on your laboratory report.
EXER C ISE 4.3.3 CULTUR I N G A E R O S O L A N D G A S S O U R C E S

For this exercise, the 1. Wash your hands thoroughly and put on gloves.
instructor will have a 2. Obtain an agar plate.
large-volume aerosol 3. Expose the surface of the plate to the aerosol directly, as shown in Figure 4.7, without allow-
delivery system available. ing the tube to touch the surface of the agar. You may use a commercially available funnel
device to minimize contamination of the sample.
4. Seal the agar plate. Label with the date, time, source of sample, and technician signature.
5. Send the sample for culturing.
6. When results are available, record them on your laboratory report.
A B C D
Figure 4.6. Swab culturing technique.
A B C
Figure 4.7. Technique for aerosol or gas source culturing.
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2679_Ch04_041-050.indd 46 07/02/13 4:43 PM
Laboratory Report
CHAPTER 4: STERILIZATION AND DISINFECTION
Name: Date:
Data Collection
EXERCISE 4.3 Monitoring Infection Control Procedures
E X E R C IS E 4. 3. 2 S WA B C U LT U RIN G
Date Time Source Results
E X E R C IS E 4 . 3. 3 C U LT U R IN G AEROSOL AN D GAS SOURCES
Date Time Source Results

1. Mrs. Pak is a 64-year-old female who has been mechanically ventilated for the last 10 days with an oral endotracheal
tube in place. You note on her chart that Pseudomonas aeruginosa has been cultured from her sputum. Describe how the
intensive care unit and mechanical ventilation may have contributed to the development of this nosocomial infection.
2. Mr. Grand is a 47-year-old man who is positive for hepatitis B. He was admitted to the ICU and you are called to
draw an arterial blood gas. Describe what infection control precautions (relating to the equipment, the patient, and
yourself) should be taken when performing an arterial blood gas on this patient.
2679_Ch04_041-050.indd 47 07/02/13 4:43 PM

3. After an unsuccessful resuscitation, you are requested to remove the manual resuscitator bag from the patient’s room.
The nondisposable bag is made of a silicone material and is soiled heavily with bloody secretions. Describe how this
equipment should be transported and disinfected.
4. Compare disinfection, decontamination, and sterilization. What procedures should be in place to ensure sterilization?
2679_Ch04_041-050.indd 48 07/02/13 4:43 PM


STUDENT: DATE:
STERILIZATION AND DISINFECTION

PERFORMANCE LEVEL
PERFORMANCE RATING
Evaluator: Setting:
Performance Level:
NA = Not applicable
Performance Rating:

1. Isolates, gathers, and transports equipment to processing site
2. Applies PPE, including gloves and gown
3. Disinfects sink (washer)
4. Fills sink, adds detergent
5. Sorts, disassembles equipment into smallest parts
6. Examines equipment for any tears, cracks, or pitting; discards defective equipment
7. Immerses equipment in solution and soaks for 20 minutes (institutes wash cycle)
8. Scrubs parts thoroughly, including any crevices
9. Rinses equipment thoroughly with tap water or sterile water, as appropriate (institutes rinse cycle)
10. Removes and sets equipment out to dry on aseptic absorbent surface equipment; drains sink
11. Prepares for appropriate sterilization method
12. Reassembles equipment; loosely secures any parts so disinfection/sterilization method can penetrate
13. Autoclave or gas sterilization: packages equipment in appropriate materials and marks with chemical or heat indicator tape
14. Cold sterilization with glutaraldehyde: checks solution expiration date; immerses equipment into solution; soaks in disinfecting solution
for 10 minutes to 10 hours, as specified; puts on sterile gloves and prepares sterile field; aseptically rinses equipment with sterile water;
dries on sterile field, and packages for storage
15. Pasteurization: loads equipment into machine and runs through cycle; dries and packages for storage
FOLLOW-UP
17. Verifies exposure to process and sterilization
18. Aerates equipment as needed (for gas sterilization)
19. Stores equipment; rotates stock
2679_Ch04_041-050.indd 49 07/02/13 4:43 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
to modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch04_041-050.indd 50 07/02/13 4:43 PM

CHAPTER Medical Record
INTRODUCTION The medical record serves as the official document regarding the patient’s medical
history, illness, treatment, and response. It is a legal document and is the source
document in any litigation. Therefore, it is extremely important that the information
accurately reflects the care rendered. Even in this day of computerized records, the old
adage “If you didn’t chart it, you didn’t do it” still rings true. Several formats can be used
to document respiratory care services. They are the narrative note, the SOAP method,
checklist charting, and charting by exception (CBE). Charting by exception assumes that
the response to an intervention was normal. Therefore, only abnormal findings are
charted. While this may seem contradictory to our old adage, most computerized
versions of CBE document and reflect the care rendered.
One of the most important sources for the information contained in the medical record is
the patient. The physician, nurse, or respiratory care practitioner (RCP) obtains very
important information by interviewing the patient concerning the circumstances of the
illness. The art of the patient interview is a skill that improves with practice. One of the
key components of the process is to put the patient at ease and establish a rapport.
Another facet of the medical record is that it contains sensitive and personal patient
information that is protected by federal law. The Health Insurance Portability and
Accountability Act (HIPAA) of 1996 protects the confidential nature of that information.
Violation of this act and the subsequent regulation known as the “Privacy Rule” issued
by the Department of Health and Human Services may result in civil or criminal
penalties.1 Because the RCP has access to this confidential information, the RCP must
never discuss this information outside of the scope of patient care.
OBJECTIVES 1. Use therapeutic communication skills to establish patient rapport and elicit information during
Upon completion of this a patient interview.
chapter, you will be able to: 2. Obtain specific patient information by reading the medical record.
3. Practice medical charting for the documentation of performance of patient assessment
procedures utilizing SOAP and narrative charting techniques.
4. Edit and organize the information for an oral case presentation.
51
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KEY TERMS
acute dyspnea laceration pathology
adenopathy dysplasia latent pathophysiology
alleviating dysphagia lesion platypnea
ambulatory electrolyte lethargic pleuritic (pain)
anemia embolism lympadenopathy pneumoconiosis
antecubital epistaxis lymphedema pneumothorax
arteriosclerosis hematocrit malaise polycythemia
asterixis homeostasis metastasis quadriplegia
ataxia Hx miliary sensorium
atherosclerosis hypertension myelitis somnolent
atrophy hypertrophy neoplasm syncope
bilateral hypervolemia obtunded systemic
cachexia hypotension orthopnea tachycardia
chronic hypovolemia orthostatic tachypnea
contraindication idipoathic pallor thrombus
decubitus (ulcer) immunosuppressed palpation vascular
demographics insidious paresthesia
diagnosis ischemia paroxysmal (cough)
Exercises
F Computerized medical documentation system, F Sample medical records
if available F Sample respiratory care notes and flow sheets
F Patient or student surrogate from clinical facilities
EXERCISE 5.1 CHART REVIEW, PATIENT INTERVIEW, AND HISTORY
Effective communication skills are necessary to establish a rapport with the patient and to elicit
useful information to supplement the physical examination. Communication also provides the pa-
tient’s perspective on the problem at hand.1 In this exercise, you will practice communication and
questioning techniques, with a fellow student acting as the patient surrogate.
EXERCISE 5 .1.1 REV IEW OF THE MED I C A L R E C O R D

Before entering the 1. Patient demographics (age, height, gender, race, religion, insurance information)
“patient’s room,” check the 2. Chief complaint/diagnosis
“chart” for all pertinent 3. History of present illness, including:
information. Your review of A. Smoking history (pack/years)
the chart should include the B. Allergies
following priority areas: C. Current medications
4. Past medical history—major surgeries, hypertension, tuberculosis, diabetes, cardiac or
pulmonary disease, and any other major illness
5. Social history—marital and family status, living arrangements, alcohol use, and sexual
activity
6. Occupational history
7. Family history
8. Results of recent diagnostic procedures (x-ray, laboratory, pulmonary function tests,
electrocardiogram, etc.)
2679_Ch05_051-068.indd 52 07/02/13 4:43 PM

C H A P T E R 5 | M EDIC AL R EC OR D • 53
9. Recent progress notes

10. Physician orders
NOTE: This activity may be performed with actual patient charts if they are available in the
lab, or by describing the information to your lab partner. It may also be performed in the
clinical setting.
11. Record your findings on your laboratory report.
EXER C ISE 5.1.2 PATIEN T I N T E R V I E W A N D H I S T O R Y

You should wash your Approach your “patient” and perform the following, demonstrating effective. Be sure to take
hands and apply standard notes so you can record the information at the end of the exercise.
precautions and transmission-
1. Introduce yourself to the “patient” and explain why you are there.
based isolation procedures as
2. Verify your “patient’s” identification by asking for the patient’s name and date of birth
appropriate. The exercise
(DOB) and checking the name band.
requires using a laboratory
3. The interview should be used to assess the following general information:
partner as a surrogate.
A. Level of consciousness and sensorium—orientation to person, place, and time. Note any
changes in mental status (since this is your lab partner, if your partner falls asleep, wake
him or her up!)
B. Ability to follow directions
C. Emotional status
D. Level of dyspnea
E. Nutritional status
F. Tolerance of activities of daily living (ADLs)
4. Ask the “patient” questions to verify the information obtained from the chart regarding the
following:
A. Demographics
B. Chief complaint: onset, duration, frequency, severity (quantity), character (quality),
location, radiation, aggravating factors, alleviating factors, associated manifestations
C. Allergies
D. Current medications
E. History of present illness, including smoking history
F. Past medical history
G. Psychosocial assessment:
i. Birthplace
ii. Race
iii. Religion
iv. Culture
v. Language(s) spoken
vi. Highest education level
vii. Sexual activity
viii. Living arrangements (e.g., live alone?)
ix. Alcohol intake
x. Drug use
H. Occupational history
i. If retired or a full-time student, be sure to find out what jobs were held in the past
that may have had risk of occupational exposure to environmental hazards.
5. Ask the “patient” questions to ascertain specific pulmonary symptoms:
A. Dyspnea—on exertion or rest; orthopnea
B. Cough
C. Sputum production—amount, color, consistency, presence of blood
D. Chest pain—quality, location, radiation, aggravating factors, alleviating factors,
associated manifestations
6. Ask the “patient” questions to determine current comfort level or needs.
7. Record your interview findings on your laboratory report.
2679_Ch05_051-068.indd 53 07/02/13 4:43 PM

Table 5.1 Some Characteristics
Listening is just as important a skill as speaking effectively. A good listener does the following:
of an Effective Listener
1. Strive to understand the person speaking by being open minded, sensitive, and compassionate, rather than simply
responding to his or her words.
2. Pay attention to a person’s tone and inflection as well as his or her choice of words, and notice the person’s body
language.
3. Give the speaker undivided attention. An effective listener shows he or she is listening by focusing on the speaker
and responding to what he or she says. An effective listener does not multitask or tune out.
4. Do not interrupt, finish the speaker’s sentences, or rush in with opinions and judgments. Be patient and allow the
speaker to complete his or her thoughts.
5. Paraphrase to make sure you have understood what the person has said. If not, seek clarification.
EXERCISE 5.2 MEDICAL RECORD DOCUMENTATION (CHARTING)
The key elements of a S = Subjective findings: usually in the words of the patient, such as “I’m still coughing”
respiratory care note are O = Objective findings: patient assessment and other data
the date and time of the A = Assessment: problem list (may include differential diagnosis)
procedure, patient P = Plan: are any modifications to the care plan necessary?
assessment before the
If a SOAP methodology is not used, the documentation may consist of a narrative note, a simple
intervention, assessment
checklist, or charting by exception. You should be familiar with the forms and types of charting
of the patient’s response
required by the clinical agencies because it is the responsibility of the RCP to document according
to the intervention, any
to facility policy.
adverse effects, and a
signature.
Some facilities use the
SOAP methodology to
construct a respiratory
care note.
EXERCISE 5 .2.1 REV IEWIN G CL IN IC A L C H A R T I N G FO R MS

Review the types of forms used by the various clinical agencies that are affiliated with your respi-
ratory care program. Compare the forms and note similarities and differences.
EXERCISE 5 .2.2 WR ITIN G A RES P IRAT O R Y C A R E N O T E

A respiratory care note may Using the following information, construct a SOAP note, a narrative note, PIP, APIE, a checklist
be written in the following note, or documentation by exception. Your instructor may ask you to use all formats. Record
forms: narrative, SOAP, PIP your notes on your laboratory report or a blank progress note form.
(problem, implementation,
Mrs. Puccini is a 65-year-old female admitted 2 days ago with chronic bronchitis. Prior to hospi-
plan), APIE (assessment,
talization, she was complaining of fever, cough, and producing large amounts of yellow-green
problem, implementation,
mucus for 5 days. She had smoked 11⁄2 packs of cigarettes per day since she was 18. Currently she
evaluation), checklist, and
is using a nasal cannula at 1 Lpm, her oxygen saturation is 92%, and her pretreatment heart rate
by exception.
is 88 beats per minute. She is still complaining of the cough and mucus production. You adminis-
ter a nebulizer treatment with 0.5 mg ipratropium bromide diluted in 3.0 mL of normal saline.
There are bilateral coarse crackles present before and after the treatment. She expectorates a
moderate amount of yellow mucus after the treatment. Her saturation is still 92% and her heart
rate is 110/minute.
RE F E RE N CE S
1. United States Department of Health and Human Services, Health Information Privacy: Summary of the HIPAA Privacy Rule, 2003.
Available at: www.hhs.gov/ocr/privacy/hipaa/understanding/summary/index.html.
2679_Ch05_051-068.indd 54 07/02/13 4:43 PM

Laboratory Report
CHAPTER 5: MEDICAL RECORD
Name: Date:
Data Collection
EXERCISE 5.1 Chart Review, Patient Interview, and History
E X E R C IS E 5. 1. 1 R E V IE W O F T HE MEDICAL RECORD
If an actual patient chart was used, record your findings on the form below:
Sex: M F F F Date of birth: Race:
Weight: Height: Ideal body weight (calculate):
Date of admission: LOS (if applicable):
CHIEF COMPLAINT:
Admitting diagnosis: Discharge diagnoses:
HPI:
Smoking history: Never smoked F Smoker F Former smoker F
Age started: Age when quit: Current age: Packs/day:
Allergies:
Current medications:
VS on admission:
PMI Do you have or have you ever had any of the following:
HEENT:
Neuro:
Eyes: Ears: Nose: Throat:
Lungs:
Dyspnea: On exertion: At rest: Position:
Cough: Sputum production: Chest pain with cough:
Cor:
Liver problems: Hepatitis: A B C:
Endocrine: Diabetes: Thyroid:
Kidney disease:
2679_Ch05_051-068.indd 55 07/02/13 4:43 PM

Gastrointestinal:
FEN (feedings/enteral/nutritional status):
Genitourinary:
Bone/muscle: Osteoporosis: Other:
Skin:
Major surgeries:
Psychosocial assessment
Birthplace: Cultural or ethnic group:
Religion: Language(s) spoken:
Highest educational level:
Sexual activity:
Alcohol intake:
Drug use (illegal, prescription, etc.):
Ambulation:
Access/Lines (chest tubes, IV, a-line, central line, etc.):

Occupational history: (If retired, what types of jobs did you have?)
Family history:
Results of recent diagnostic procedures:
Recent progress notes:
Current physician orders:
Outcome:
2679_Ch05_051-068.indd 56 07/02/13 4:43 PM

E X E R C IS E 5. 1. 2 PAT IE N T IN T ERVIEW AN D HISTORY
Sex: M F F F Date of birth: Race:
Weight: Height: Ideal body weight (calculate):
Date of admission: LOS (if applicable):
CHIEF COMPLAINT:
Diagnosis:
HPI:
LOC:
Smoking history: Never smoked F Smoker F Former smoker F
Age started: Age when quit: Current age: Packs/day:
Allergies:
Current medications:
Ambulation/assess ADLs:
PMI Do you have or have you ever had any of the following:
Major surgeries:
HEENT:
Neurological problems:
Seizure history:
Eyes: Ears: Nose: Throat:
Teeth: Dentures:
Lungs:
Asthma: Since:
Emphysema: Since:
Bronchitis: Pneumonia:
Tuberculosis: Other:
Dyspnea: On exertion: At rest: Position:
Cough: Sputum production: Chest pain with cough:
Heart: Chest pain:
Hypertension:
Heart attack: Pacemaker:
Liver problems: Hepatitis: A B C:
Endocrine: Diabetes: Thyroid:
Kidney disease:
2679_Ch05_051-068.indd 57 07/02/13 4:43 PM

Gastrointestinal:
GERD: Ulcers: Bowel problems:
FEN (feedings/enteral/nutritional status):
Genitourinary:
Bone/muscle: Osteoporosis: Other:
Skin:
Psychosocial assessment
Birthplace: Cultural or ethnic group:
Religion: Language(s) spoken:
Highest educational level:
Sexual activity:
Alcohol intake:
Drug use (illegal, prescription, etc.):

Occupational history: (If retired, what types of jobs did you have?)
Family history:
Results of recent diagnostic procedures:
Recent progress notes:
Current physician orders:
2679_Ch05_051-068.indd 58 07/02/13 4:43 PM

EXERCISE 5.2 Medical Record Documentation (Charting)
E X E R C IS E 5. 2. 2 W R IT ING A R ESPIRATORY CARE N OTE
Note (or attach progress note form if instructed to do so)
S:
O:
A:
P:

1. The staff RCP tells you that sometimes she is just too busy to chart all her treatments. Discuss the implications of not
charting.
2. A celebrity sports figure is admitted to your hospital. That night, your best friend calls after hearing about the hospital-
ization on the evening news. She wants to know why he was admitted and if he had an HIV test. How do you respond?
3. What precautions should be taken to ensure patient confidentiality when using an electronic medical record? Is it
acceptable to fax patient information?
4. You answer the phone at the nursing station and the caller asks you “How is my Aunt Mary in room 2012 doing?”
How do you respond?
2679_Ch05_051-068.indd 59 07/02/13 4:43 PM

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STUDENT: DATE:
MEDICAL RECORD REVIEW

PERFORMANCE LEVEL
PERFORMANCE RATING
Evaluator: Setting:
Performance Level:
NA = Not applicable
Performance Rating:
5 Independent: Near flawless performance; minimal errors; able to perform without supervision; seeks out new learning;

1. Obtains and verifies correct chart or electronic medical record
2. Informs nurse or unit secretary if removing chart from the nurses’ station
3. Ensures compliance with HIPAA regulations regarding personal health information

4. Locates and evaluates:
A. Patient demographics
B. Chief complaint/diagnosis
C. History of present illness
D. Smoking history (pack/years)
E. Past medical history
F. Allergies
G. Current medications
H. Psychosocial history
I. Occupational history and exposures
J. Family history
5. Locates and evaluates the physician’s orders or protocols
6. Reviews physical examination results
7. Reviews results of current diagnostic procedures including CXR, EKG, PFT, ABGs, labs
8. Reads and evaluates most recent progress notes
9. Charts procedure performed or shift note including all pertinent data
10. Signs note with appropriate credential and has preceptor/instructor countersign
FOLLOW-UP
11. Develops and documents SOAP, APIE, and care plan
12. Returns chart to proper location and/or closes electronic record
2679_Ch05_051-068.indd 61 07/02/13 4:43 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch05_051-068.indd 62 07/02/13 4:43 PM


STUDENT: DATE:
MEDICAL RECORD DOCUMENTATION
PERFORMANCE LEVEL
PERFORMANCE RATING
Evaluator: F Peer F Instructor Setting: F Lab F Clinical Simulation
Performance Level:
NA = Not applicable
Performance Rating:
1. Identifies and selects the proper medical record

2. Identifies the proper section of the chart for documenting respiratory care services
3. Dates and times the entry
4. Charts the respiratory care procedure according to facility policy
5. Includes all patient assessment data
6. Includes medication dosage and mode of delivery, if indicated
7. Charts patient response to therapy
8. Signs the note (including credential) according to facility policy
9. If a paper record is used, returns the chart to the proper location
10. If an electronic record is used, closes the record and logs off the computer
2679_Ch05_051-068.indd 63 07/02/13 4:43 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch05_051-068.indd 64 07/02/13 4:43 PM


STUDENT: DATE:
PATIENT INTERVIEW AND HISTORY
PERFORMANCE LEVEL
PERFORMANCE RATING
Performance Level:
NA = Not applicable
Performance Rating:

2. Limits distractions; performs in quiet location

4. Utilizes therapeutic communication skills to determine level of consciousness and sensorium, orientation to person, place, time
5. Assesses ability to follow directions and level of cooperation
6. Evaluates emotional status, level of dyspnea, nutritional status, and tolerance of activities of daily living (ADLs)
7. Asks patient chief complaint: onset, duration, frequency, severity (quantity), character (quality), location, radiation, aggravating factors,
alleviating factors, associated manifestations
8. Asks about history of present illness
9. Determines smoking history (pack years)
10. Inquires about allergies and current medications
11. Asks the patient questions to ascertain specific pulmonary symptoms: dyspnea on exertion or rest, orthopnea, platypnea, pleurodynia
12. Asks about nature of cough
13. Inquires about sputum production: amount, color, consistency, odor, taste, presence of blood
14. Inquires about chest pain: quality, location, radiation, aggravating factors, alleviating factors, and associated manifestations
15. Inquires about past medical history, major illnesses, injuries, and surgeries
16. Performs psychosocial assessment as applicable:
A. Birthplace F. Highest education level
B. Race G. Alcohol intake
C. Religion H. Sexual activity
D. Culture I. Drug use
E. Language(s) spoken J. Home situation
17. Asks questions about occupational history and exposures
18. Performs review of systems (ROS) to ensure all pertinent information has been obtained
19. Asks the patient questions to determine current comfort level or needs
FOLLOW-UP
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PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch05_051-068.indd 66 07/02/13 4:43 PM


STUDENT: DATE:
CASE STUDY PRESENTATION
PERFORMANCE LEVEL
PERFORMANCE RATING
Performance Level:
NA = Not applicable
Performance Rating:


3. Interviews patient and collects history
4. Performs physical examination
ORAL CASE PRESENTATION

6. Identifies self to audience
7. Maintains patient confidentiality
8. Relates patient information including: age, gender, race, height, and weight
9. Relates advances directive status (full code, DNR)
10. States chief complaint concisely
11. States history of present illness (tells the story)
12. States past medical history including major illnesses, injuries, and surgeries
13. States psychosocial history
14. Identifies employment history including present and past employment
15. Identifies family history
16. Identifies result of review of systems (ROS)
17. Identifies results of physical examination including date and time performed
18. Presents case in chronological order (tells the story)
19. Presents discussion and summary
20. Presents complete care plan
21. Maintains poise and composure throughout presentation
22. Speaks clearly and loudly enough so audience can hear and comprehend
23. Answers questions of audience and instructors in reasonable time frame
24. Correlates theory to case presentation
25. Completes presentation in reasonable time frame (15 to 30 minutes)
26. Prepares and submits written case according to instructions
2679_Ch05_051-068.indd 67 07/02/13 4:43 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
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CHAPTER Patient
Assessment: Basic
Skills—Vital Signs
INTRODUCTION Effective patient assessment is the single most important component in providing
competent respiratory care. Initiation, modification, and discontinuance of all respiratory
care procedures depend on adequately assessing the patient’s changing condition.1
Incorporating assessment data with the information gathered by the patient interview
gives the respiratory care practitioner (RCP) a clearer understanding of the patient’s
clinical picture. Therefore, to effectively participate in the decision-making process or to
successfully implement respiratory care and therapist-driven protocols (TDPs), the RCP
must be proficient in patient assessment techniques.
The basic elements of patient assessment include the following:

1. Scene survey
2. Primary survey
3. Secondary survey
4. Vital signs
5. Pulse oximetry
This chapter will focus on the basic techniques of vital sign assessment, including pulse
oximetry. We will explore pulse oximetry and other noninvasive blood gas monitoring
techniques more comprehensively in Chapter 25. The more advanced skills of physical
assessment of the chest and auscultation will be discussed in the next chapter.
OBJECTIVES 1. Conduct a primary survey.

Upon completion of this
chapter, you will be able to: 2. Perform a secondary survey (head-to-toe assessment).
3. Practice the techniques of simple vital sign measurements:
A. Temperature
B. Pulse
C. Breathing
D. Blood pressure
4. Perform pulse oximetry.
5. Practice medical charting for documenting performance of patient assessment procedures.
6. Apply infection control guidelines and standards associated with equipment and procedures
according to OSHA regulations and CDC guidelines.
69
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KEY TERMS
While many of these key terms are not in the chapter, they may be used to discuss patient status
during assessment.
atelectasis clubbing hyperpnea posterior
aneroid collateral hyperthermia prone
anterior cyanosis hypopnea proximal
apical debilitated hypothermia respiration
apnea decubitus ulcer inferior sphygmomanometer
aspiration diaphoresis invasive stoma
asymmetrical diastole jaundice subcutaneous
auscultation diastolic pressure Kussmaul’s respiration emphysema
binaural systole lateral superior
Biot’s respiration distal medial systolic pressure
blanching ecchymosis pallor torr
bradycardia edema palpation turgor
cachectic epithelium paradoxical respiration unilateral
catheter erythema paresthesia vasoconstriction
caudad eupnea percussion vasodilation
cephalad febrile perfusion ventilation
Cheyne-Stokes respiration flaring phalanges
Exercises
F Alcohol prep pads F Patient mannequin (or student)
F Binaural stethoscopes (teaching models, if F Pulse oximeter and probes (disposable and
available) permanent)
F Disposable (nonlatex) gloves, various sizes F Sphygmomanometer
F Electronic digital oral or ear thermometers F Stopwatch
and sheaths F Various pulse oximeter probes
F Hospital bed or equivalent F Various size blood pressure cuffs
F Human patient simulator mannequin (if available) F Watch with second hand
EXERCISE 6.1 PRIMARY SURVEY
It is expected that you will have already had instruction in basic life support for health-care
providers before performing these laboratory exercises.
The primary survey includes the initial impression of the patient, observing for any immediate
life-threatening conditions only. The primary survey consists of checking airway, breathing,
and circulation (the ABCs): Airway—is the airway open? Breathing—is breathing present?
Circulation—is a pulse present? Is there any severe bleeding? Immediate action must be taken
for any life-threatening condition before proceeding to the next step.
In this exercise, your instructor will set up one or more of the following scenarios. The American
Heart Association (AHA) 2010 cardiopulmonary resuscitation (CPR) guidelines have changed the
resuscitation sequence to C-A-B.2 Refer to the current guidelines for specific details.
You should apply standard precautions and transmission-based isolation procedures as appropri-
ate. Remember to check the scene for safety (see Chapter 1) before approaching the patient.
Record your findings on your laboratory report. Approach the “patient” and assess the ABCs.
Perform any necessary steps as determined by your findings.
1. Fora conscious and alert patient who is breathing and has a pulse:
A. Determine responsiveness.
B. Quickly observe the patient for chest rise and fall.
C. Ask the patient a question that requires a response to determine whether the subject has
a patent airway and is able to move air.
D. Quickly observe for any severe bleeding by scanning the patient from head to toe.
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C H A P T E R 6 | PAT I E N T A S S E S S M E N T: B A S I C S K ILLS —V ITAL S IGNS • 71
2. For an unconscious patient who is breathing and has a pulse:
A. Determine unresponsiveness.
B. Activate the emergency medical services (EMS) system.
C. Use the head tilt/chin lift maneuver (Fig. 6.1) to open the airway. Look, listen, and feel
for breathing (Fig. 6.2). If spinal injury is suspected, use a modified jaw thrust (Fig. 6.3)
to open the airway.
i. If the patient is breathing, maintain the head tilt/chin lift position with one hand.
Continue to monitor for breathing and carotid pulse.
3. For an unconscious patient who is not breathing but who has a pulse:
B. Activate the EMS system.
C. Use the head tilt/chin lift maneuver to open the airway, and maintain it with one hand.
Look, listen, and feel for breathing.
D. If breathing is absent, begin rescue breathing. Various methods of ventilation are shown
in Figure 6.4.
E. Practice mouth-to-mask ventilation, as shown in Figure 6.5.
NOTE: Ventilations should be simulated if a student is acting as the surrogate patient.
F. Check the carotid pulse for 5 to 10 seconds (Fig. 6.6). If the pulse is present, continue
rescue breathing. Monitor the pulse periodically.
4. For an unconscious patient who is not breathing and has no pulse:
B. Activate the EMS system.
C. Check for a pulse (less than 10 seconds).
D. If a pulse is absent, begin chest compressions (Fig. 6.7) and continue CPR according to
current AHA guidelines.
NOTE: Compressions should be simulated if a student is acting as the surrogate patient.
Figure 6.1. Opening the airway. (Reproduced

with permission from Venes, D [ed]: Taber’s
Cyclopedic Medical Dictionary, ed. 21.
FA Davis, Philadelphia, 2009, p. 2018.)
Figure 6.2. Determining breathlessness.

(Reproduced with permission from Venes, D [ed]:
Taber’s Cyclopedic Medical Dictionary, ed. 21.
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72 • LABORATORY E XE RCI SE S F OR COM PE T E NCY I N R E S P I R AT O RY C A R E
Figure 6.3. Jaw-thrust maneuver.

(Reproduced with permission from Myers,
E: EMS Notes: EMT & Paramedic Field
Guide. FA Davis, Philadelphia, 2009, p. 5.)
A B
Figure 6.4. Methods of rescue breathing: (A) Mouth-to-mouth

breathing, (B) Mouth-to-nose breathing, (C) Mouth-to-stoma
breathing. (Reproduced with permission from Venes, D [ed]:
Taber’s Cyclopedic Medical Dictionary, ed. 21. FA Davis,
Philadelphia, 2009, p. 2018.) C
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Figure 6.5. Mouth-to-mask ventilation with a one-way

valve and supplemental oxygen. (Courtesy of Laerdal
Medical Corporation, Wappingers Falls, NY.)
Figure 6.6. Checking the carotid pulse.

(Reproduced with permission from Myers, E:
EMS Notes: EMT & Paramedic Field Guide.
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Figure 6.7. Proper positioning for chest compressions. (Reproduced with permission from Venes, D [ed]: Taber’s Cyclopedic Medical Dictionary, ed. 21. FA Davis,
Philadelphia, 2009, p. 2020.)
EXERCISE 6.2 SECONDARY SURVEY
The secondary survey is a Perform a brief head-to-toe survey of your lab partner or human patient simulator, as shown in
brief head-to-toe observation Figure 6.8. Wash your hands and apply standard precautions and transmission-based isolation
of your patient to ascertain procedures as appropriate.
any injuries or problems
other than the chief 1. Head. Examine the head as follows:
complaint that may require A. Observe and palpate for the presence of any cuts or bruises.
attention. B. Inspect the nose and ears for fluid or blood.
C. Inspect the mouth for blood, broken teeth, or loose teeth.
D. Check the breath odor.
E. Check skin temperature and texture.
F. Check mucous membranes for color.
2. Neck. Inspect and palpate the neck for the following:
A. Any masses
B. Jugular vein distention (JVD)
C. Medical alert pendant or bracelet
D. Presence of stoma
E. Subcutaneous emphysema
F. Tracheal deviation
2679_Ch06_069-094.indd 74 07/02/13 4:43 PM

A B
C D
E F
G H
Figure 6.8. Head-to-toe survey. I J
G. Transtracheal oxygen catheter

H. Use of accessory muscles
I. Any other invasive catheters
3. Chest. This area will be covered in Exercise 6.3.
4. Abdomen. Palpate the four quadrants and observe for the following:
A. Pain
B. Distention
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C. Rigidity
D. Bruising
5. Extremities. Observe and palpate for the following:
A. Deformities
B. Edema (Fig. 6.9)
C. Peripheral pulses
D. Temperature and color
E. Capillary refill
F. Clubbing of the distal phalanges (Fig. 6.10)
G. Tobacco stains on the fingers
H. Medical alert pendant or bracelet
1⫹ pitting edema 2⫹ pitting edema
3⫹ pitting edema 4⫹ pitting edema
Figure 6.9. Evaluating pitting edema. (From Morton, PG: Health Assessment in Nursing, ed. 2. FA Davis, Philadelphia, 1993, p. 399, with permission.)
Figure 6.10. Clubbing. (From Morton, PG: Health Assessment in Nursing, ed. 2. FA Davis, Philadelphia, 1993, p. 261, with permission.)
2679_Ch06_069-094.indd 76 07/02/13 4:43 PM

EXERCISE 6.3 VITAL SIGNS

EXER C ISE 6.3.1 TAK IN G O R A L/ A X I LLA R Y / E A R T E MP E R AT U R E S
You will measure the axillary, 1. Place the thermometer probe in a disposable sheath.
oral, and ear temperatures of 2. Press the “Start” button.
a laboratory partner. Various 3. Place the probe of the thermometer under your lab partner’s tongue and leave it in place
thermometers are shown in until the thermometer indicates a final reading (several seconds).
Figure 6.11. The causes of 4. Remove the thermometer, discard the sheath, and record the temperature on your laboratory
hyperthermia and report.
hypothermia are shown in 5. Repeat for the axillary temperature with a nondisposable thermometer. Keep under the arm
Table 6.1. for at least 10 minutes and record the temperature on your laboratory report.
Wash your hands and 6. Repeat for the tympanic temperature (ear temperature as available) and record the
apply standard precautions temperature on your laboratory report.
and transmission-based
isolation procedures as
appropriate.
Figure 6.11. Several types of thermometers

measure body temperature: chemical dot,
digital, and electronic digital. Each type
provides accurate readings when used
properly. (From Morton, PG: Health Assessment
in Nursing, ed. 2. FA Davis, Philadelphia, 1993,
p. 74, with permission.)
Table 6.1 Causes of Hypother-

Causes of Hypothermia Causes of Hyperthermia
mia and Hyperthermia
Cold exposure Fever
Shock, blood loss Heat exposure
Drugs Drugs
Brain injuries Dehydration
Anesthesia
Atelectasis
Surgery
Brain injuries
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EXERCISE 6 .3 .2 LOC ATION AN D MEA S U R E ME N T O F P U LS E

1. To locate common pulse points: Wash your hands and apply standard precautions and
transmission-based isolation procedures as appropriate. Identify the following pulse points
as shown in Figure 6.12 on your laboratory partner or yourself:
Radial
Brachial
Carotid
Femoral
Popliteal
Dorsalis pedis
Posterior tibial
NOTE: To properly palpate pulses, use the index and middle fingers as shown in Figure 6.12. Do
not use the thumb. Press firmly but gently. Excessive pressure can obliterate the pulse. Ideally, the
pulse should be measured for a full minute, particularly in subjects with an irregular heart rate or
rhythm.
2. To measure the pulse rate: Wash your hands and apply standard precautions and
transmission-based isolation procedures as appropriate.
A. Using a watch with a second hand, measure your partner’s radial pulse for 15 and
60 seconds. Record the results on your laboratory report.
B. Describe the quality of the pulses you felt. Include an assessment of pulse strength and
regularity. Record this on your laboratory report.
C. Have your partner run or up and down a flight of stairs or run in place for 1 minute.
Remeasure the radial pulse. Record the result on your laboratory report.
Brachial
Radial Carotid
A B C
Popliteal
Femoral Dorsalis pedis
D E F
Figure 6.12. Palpation of pulses: (A) radial pulse, (B) brachial pulse, (C) carotid pulse, (D) femoral pulse, (E) popliteal pulse, (F) dorsalis pedis, and
2679_Ch06_069-094.indd 78 07/02/13 4:43 PM

Posterior tibial
Figure 6.12.—cont’d (G) posterior tibial. (From Morton, PG:

Health Assessment in Nursing, ed. 2. FA Davis, Philadelphia, 1993,
pp. 312–313, with permission.)
G
3. To measure the apical radial pulse: The apex of the heart is located on the left side of the
chest. You can hear the heart beating with a stethoscope. The causes of bradycardia and
tachycardia are shown in Table 6.2.
A. Measure the apical pulse rate on your laboratory partner and compare it with the result
from step 2.
B. Record the pulse rate on your laboratory report.
4. To assess capillary refill: Capillary refill helps one assess local perfusion.
A. Gently squeeze the tip of each finger (one at a time) until a blanching is noticed (nail bed
turns white), as shown in Figure 6.13.
B. Using a stopwatch, record the time it takes for the fingertip to turn pink. A slow refill
(longer than 3 seconds) indicates poor perfusion.
Table 6.2 Causes of Bradycardia

Causes of Bradycardia Causes of Tachycardia
and Tachycardia
Heart block Hypoxia
Athletic conditioning Fever
Hypothermia Anxiety/stress
Severe trauma Pain
Adrenergic blocking agents Drugs
Vagal stimulation Hyperthyroidism
Increased intracranial pressure Shock
Drugs Hypercapnia
Heart dysrhythmias
Figure 6.13. Assessing capillary refill. A B
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EXERCISE 6 .3.3 AS S ESSMEN T OF BRE AT H I N G ( R E S P I R AT I O N )

1. To measure respiratory frequency:
A. Wash your hands and apply standard precautions and transmission-based isolation
procedures as appropriate.
B. Observe your partner’s chest for movement. The chest rises during inspiration. The
beginning of one inspiration to the beginning of the next is one full respiration cycle.
NOTE: Many patients unintentionally alter their respiratory rate or pattern if they become aware
that you are counting their respirations. This can be avoided if you appear to be taking the pulse
while you are actually counting the respiratory rate.
C. Using a watch with a second hand, count your partner’s respirations (f) for 15 and
60 seconds. Record the results on your laboratory report.
D. Describe the quality of the respirations you observed. Assessment should include
evaluation of the rate and depth, whether there is labored breathing, and the pattern of
respiration.
2. To assess the inspiration:expiration (I:E) ratio:
Expiration is normally twice as long as inspiration. The ratio of inspiratory time (I) to
expiratory time (E) should be approximately 1:2. It is extremely difficult to manually
measure the I:E ratio. In a clinical setting (e.g., a patient on mechanical ventilation) the I:E
ratio is measured by computerized technology. However, it is clinically important to be able
to assess and compare the length of inspiratory and expiratory cycles with “normal.”
Formulas:
f = respiratory rate
T (total time) = 60/f
E=T–I
I=T–E
I:E = 1:E/I
I = T/I + E
A. Using a watch with a second hand, measure the time it takes for one full respiration
from the beginning of inspiration to the beginning of the next inspiration. Record the
results on your laboratory report.
B. Watch your laboratory partner closely. Measure your partner’s inspiratory time (from
the beginning of inspiration to the beginning of expiration) in seconds. Record the
C. Measure your partner’s expiratory time (from the beginning of expiration to the
beginning of inspiration) in seconds. Record the results on your laboratory report.
NOTE: The inspiratory time and expiratory time should equal the total time. Because of the diffi-
culty of manual measurement, times may not be exact.
EXERCISE 6 .3.4 AR TER IAL BLOOD P R E S S U R E

Most health-care facilities To measure blood pressure with an aneroid sphygmomanometer, take your laboratory partner’s
have aneroid blood pressure while he or she is sitting. Record the results on your laboratory report.
sphygmomanometers 1. Wash or sanitize your hands and apply standard precautions and transmission-based
mounted on a wheeled cart isolation procedures as appropriate.
or on the wall (Figure 6.14). 2. Wrap the sphygmomanometer cuff snugly around your partner’s arm approximately 1 inch
Some facilities may be using above the inner aspect of the elbow (the antecubital area), as shown in Figure 6.15. Proper
various types of electronic cuff size is essential. The cuff should be about 1.5 times the size of the limb. Ensure that the
devices. cuff bladder is centered over the brachial artery. Most cuffs have arrows to indicate artery
and cuff alignment. The gauge should be kept at the level of your partner’s arm. Your
partner’s arm should be kept at heart level. The arm must remain relaxed. Any muscle
tension used to keep the arm straight will alter the reading.
3. Palpate the brachial pulse and then rapidly inflate the cuff to approximately 30 mm Hg
above the level at which the pulse disappears.
4. Deflate the cuff slowly until the pulse reappears. Make a mental note of that number.
Deflate the cuff completely.
5. Place the stethoscope in your ears and place the bell of the stethoscope over the brachial
pulse, slightly distal to or partially under the cuff, as shown in Figure 6.16.
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Figure 6.14. Aneroid

sphygmomanometer. (From Morton,
PG: Health Assessment in Nursing,
ed. 2. FA Davis, Philadelphia, 1993,
Figure 6.15. Blood pressure cuff

application. (From Morton, PG: Health
Assessment in Nursing, ed. 2. FA Davis,
Philadelphia, 1993, p. 99, with
permission.)
Figure 6.16. Measuring blood pressure.

(From Morton, PG: Health Assessment in
Nursing, ed. 2. FA Davis, Philadelphia,
1993, p. 99, with permission.)
6. Watching the manometer, pump up the cuff until the level is about 30 mm Hg above the
point at which the pulse disappeared (from step 4).
7. Slowly open the air valve to deflate the cuff and watch carefully as the needle drops. The
speed should be approximately 2 to 4 mm Hg per second.
8. While watching the manometer, listen for the sound of blood pulsating through the brachial
artery. The point at which this occurs is the systolic pressure. Make a mental note of this
number. This is the systolic pressure.
9. Continue to deflate the cuff at the same rate until all sound disappears. Note this number.
This is the diastolic pressure.
10. Remove the cuff and record the blood pressure on your laboratory report as systolic/
diastolic.
11. Repeat the blood pressure measurement while your partner is standing and then lying
down. Record these measurements on your laboratory report.
12. Have your partner run in place for 1 minute and then repeat the standing blood pressure
measurement. Record the measurement on your laboratory report.
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EXERCISE 6.4 BASIC PULSE OXIMETRY
Pulse oximetry has become the fifth vital sign. This noninvasive technique of quickly assessing
oxygenation status is simple and should be done during initial patient assessment and as often
as necessary. It is important to report the results in conjunction with any oxygen therapy. If the
reading was obtained on room air, include this information in the findings. Pulse oximetry will
be explored in more depth in Chapter 25.
Obtain a pulse oximetry reading on your partner and record the results on your laboratory report.
1. Wash or sanitize your hands and apply standard precautions and transmission-based
isolation procedures as appropriate.
2. Select a pulse oximeter and finger probe.
3. Turn the unit on and ensure that it is functioning.
4. Select a finger and ensure that there is adequate circulation to the digit.
5. Apply the probe as shown in Figure 6.17.
6. Wait about 30 seconds for the reading to stabilize.
7. Observe both the oximetry and pulse reading. Does the pulse correlate with your findings in
Exercise 6.3.2?
8. Note whether the “patient” is breathing room air or supplemental oxygen.
9. Record the pulse, oximetry, and oxygen percentage on your laboratory report.
Figure 6.17. Proper orientation of oximeter

finger probe.
RE F E RE N CE S
1. Wilkins, RL, Dexter, JR, and Heuer, AJ: Clinical Assessment in Respiratory Care, ed. 6. Mosby, St. Louis, 2010, p. xi.
2. Berg, RA, et al: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care science.
Circulation 122:S640–S933, 2010.
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Laboratory Report
CHAPTER 6: PATIENT ASSESSMENT: BASIC SKILLS—VITAL SIGNS
Name: Date:
Data Collection
EXERCISE 6.1 Primary Survey
Findings: ____________________________________________________________________________________________________
____________________________________________________________________________________________________________
EXERCISE 6.2 Secondary Survey
Head _______________________________________________________________________________________________________
Neck _______________________________________________________________________________________________________
Chest ______________________________________________________________________________________________________
Abdomen ___________________________________________________________________________________________________
Extremities __________________________________________________________________________________________________
EXERCISE 6.3 Vital Signs
EXERCISE 6.3.1 TA K IN G O R A L/A XIL L ARY/EAR TEMPERATURES
Temperature: Oral = ______°F, Axillary = ______°F, Tympanic = _____°F
Convert the temperatures to Celsius: °C = 5(°F – 32)/9. Show your work.
Oral = ______°C
Axillary = ______°C
Tympanic = ______°C
Convert 39° Celsius to Fahrenheit: °F = °C × 9/5 + 32. Show your work.
Temperature = _______°F
EXERCISE 6.3.2 LO C AT IO N A N D M EASUREMEN T OF PUL SE
60-second pulse = ______/minute. ________________________________________ 15-second pulse = ______ × 4 = ______/minute
Compare the two measurement methods: __________________________________________________________________________
____________________________________________________________________________________________________________
Quality of pulse: ______________________________________________________________________________________________
Pulse after exercise = ______/minute __________________________________________ Apical pulse rate (resting) = ______/minute
Pulse deficit = apical – radial = ______/minute ________________________________________ Capillary refill time = ______seconds
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EXERCISE 6.3.3 A S S E S S M E N T O F B R E AT H IN G (RESPIRATION )
1. Measuring respiratory frequency
A. f: 15 seconds = ______× 4 = ______/minute.
B. f: 30 seconds = ______/minute
C. Quality of respirations: _________________________________________________________________________________
2. Inspiration:expiration ratio
A. Measured respiratory total time = _________________ seconds
B. Measured inspiratory time = ____________________ seconds
C. Measured expiratory time = ____________________ seconds
3. Calculating expiratory time. Using steps 2A and 2B, calculate the following. Show your work.
A. Expiratory time T – I = E ______ (seconds)
B. I:E ratio = 1: ______
C. Measured expiratory time = ______ seconds
4. Calculating inspiratory time. (Do not use your measured value of I time for this calculation!) Using steps 2.A and 2.C, calculate the
following. Show your work.
A. T – E (measured) = I ___________ seconds
B. I:E ratio = 1: _____________
EXERCISE 6.3.4 A R T E R IA L B L O O D P R E S S U R E
1. Blood pressure (BP) sitting = ______ mm Hg
2. Pulse pressure = Systolic – Diastolic = ______
3. BP standing = ______ mm Hg
4. BP supine = ______ mm Hg
5. BP after exercise = ______ mm Hg
EXERCISE 6.4 Basic Pulse Oximetry
1. Pulse: ____________________________ 3. Pulse correlation: ______________________
2. Oximetry reading: ___________________ 4. Oxygen or room air: ____________________

1. When would it be recommended to count the pulse for 30 to 60 seconds rather than 15 seconds?
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2. What conditions or circumstances may cause the apical and radial pulse to be different from each other?
3. A patient is noted to be tachycardic with a pulse rate of 140/minute. What other signs and symptoms would you
expect to find on physical examination if the tachycardia is caused by hypoxia?
4. Name two respiratory care procedures or modalities that can interfere with the accurate measurement of an oral
temperature.
5. Convert the following Fahrenheit temperatures to Celsius. Show your work.
A. 95 °F = ______________°C
B. 105 °F = __________________°C
6. If the patient’s total respiratory time and respiratory rate stayed the same but expiratory time was increased, would
inspiratory time increase or decrease?
7. If the patient’s total respiratory time is 6 seconds, what would this person’s respiratory rate per minute be? Show your
work.
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8. If a patient’s I:E ratio is 1:2 and expiration is 4 seconds long, what would the inspiratory time be? Show your work.
9. If a patient’s I:E ratio is 1:3 and respiratory rate is 30/minute, calculate the following. Show your work.
T = ______________
Inspiratory time = __________
Expiratory time = ____________
10. Explain how and why pulsus paradoxus occurs.
11. Differentiate between pulsus paradoxus and pulsus alternans.
12. How will the blood pressure measurement be affected if excessive pressure is used in cuff inflation or if pressure is held
in the cuff too long?
13. What happens if a blood pressure cuff is too small?
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14. You have entered the patient’s room to administer a respiratory treatment. You find the patient lying face down on the
bathroom floor.
A. What are the first three steps you would take under these circumstances?
B. You have determined that the victim is not breathing. You attempt manual ventilation and do not see the chest
rise and fall or feel air entering the victim. What are the first three steps you would take under these circum-
stances?
15. A patient with diabetes enters the emergency department (ED) in a coma. You perform a basic assessment on this
patient.
A. What would you expect to find when assessing the patient’s breath?
B. The patient’s capillary refill time is noted to be 10 seconds. What would this indicate? Why?
C. What type of respiratory rate and pattern would you expect to find?
16. You are called to the ED to evaluate Mr. C.O. Tu. Mr. Tu has a long-standing history of chronic obstructive pulmonary
disease (COPD). He has been brought to the ED by ambulance. He complains of increasing shortness of breath and
productive cough with thick, green sputum.
A. Identify five clinical findings you could detect by direct observation that would indicate to you that Mr. Tu has
increased work of breathing.
B. What values would you expect to find when measuring vital signs (pulse, respirations, blood pressure, and
temperature) and pulse oximetry?
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2679_Ch06_069-094.indd 88 07/02/13 4:43 PM

STUDENT: DATE:
VITAL SIGNS: PULSE AND RESPIRATION

PERFORMANCE LEVEL
PERFORMANCE RATING
Evaluator: Setting:
Performance Level:
NA = Not applicable
Performance Rating:


3. Locates pulse site
4. Measures pulse for at least 15 seconds, or a full minute if pulse is irregular
A. Assesses rhythm and quality of the pulse
5. Measures respiration for at least 15 seconds
A. Assesses depth of breathing and I:E ratio
B. Assesses rhythm and quality of respirations
6. Assesses degree of labored breathing, orthopnea, platypnea, pleurodynia, accessory muscle use, pursed-lip breathing, retractions,
nasal flaring, and abdominal paradox
7. Measures pulse oximeter saturation and pulse reading (see PCE for Pulse Oximetry)
8. Compares pulse reading to oximeter or cardiac monitor rate
9. Measures blood pressure (see PCE for Blood Pressure)
10. Looks up and notes patient’s temperature on vital signs flow sheet or chart
FOLLOW-UP
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PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
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STUDENT: DATE:
BLOOD PRESSURE
PERFORMANCE LEVEL
PERFORMANCE RATING
Evaluator: Setting:
Performance Level:
NA = Not applicable
Performance Rating:


3. Determines patient’s usual blood pressure readings, if able
4. Selects correct size sphygmomanometer cuff for patient’s age and weight
5. Wraps cuff snugly around patient’s arm (should wrap 1-1/2 times)
6. Positions aneroid gauge level with arm at heart level
7. Has patient relax arm while supporting it
8. Palpates brachial pulse and inflates cuff approximately 30 mm Hg above level until pulse disappears
A. Notes pressure at point when pulse disappears
9. Deflates cuff slowly until pulse reappears
A. Notes pressure at that point
10. Places stethoscope in ears and places bell of stethoscope over the brachial pulse, slightly distal to or partially under cuff
11. Reinflates cuff 30 mm Hg above expected systolic pressure determined in steps 8 and 9
12. Deflates cuff slowly, observing manometer; notes systolic and diastolic pressures
13. Completely deflates and removes cuff
14. Records the blood pressure
FOLLOW-UP
15. Common Performance Elements Steps 11–16
2679_Ch06_069-094.indd 91 07/02/13 4:43 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch06_069-094.indd 92 07/02/13 4:43 PM


STUDENT: DATE:
PULSE OXIMETRY
PERFORMANCE LEVEL
PERFORMANCE RATING
Evaluator: Setting:
Performance Level:
NA = Not applicable
Performance Rating:


2. Determines FIO2 and/or ventilator settings
3. Visually inspects the power cord (if applicable) and probes cable for any frayed or exposed wires
5. Assesses patient by measuring the patient’s pulse rate manually and/or verifying the heart rate displayed on ECG monitor (if applicable)
6. Confirms the FIO2 and/or ventilator settings in the patient’s room
7. Turns on the oximeter and allows for appropriate warm-up
8. Selects a site for the probe application and checks for adequate perfusion; removes nail polish or artificial nails if necessary
9. Cleans site and nondisposable probe with alcohol prep pad
10. Attaches probe to the selected site and secures
11. Allows for proper stabilization
12. Observes the pulse rate on the oximeter and correlates it with the manually measured rate and/or ECG rate
13. Records the pulse rate, saturation, respiratory rate, and pattern
FOLLOW-UP
15. Disconnects and turns unit off if not a continuous monitoring situation
16. Disinfects probe if nondisposable
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PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
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CHAPTER Patient
Assessment:
Advanced Skills
INTRODUCTION The next steps in the assessment of the patient by the respiratory care practitioner (RCP)
are the physical examination of the chest and auscultation of breath sounds. To achieve
proficiency, these skills require practice and exposure to many different types of patients
in varying clinical scenarios. The data obtained from physical examination of the chest
and auscultation, combined with the primary and secondary scene survey and vital signs,
can be used to formulate or amend a respiratory care plan. In this chapter, the following
skills will be practiced:
1. Physical assessment of the chest
A. Inspection
B. Palpation
C. Diagnostic chest percussion
2. Auscultation
OBJECTIVES 1. Practice the physical assessment techniques of inspection, palpation, and percussion
Upon completion of this of the chest.
chapter, you will be able to: 2. Practice auscultation.
3. Differentiate the various breath sounds heard during auscultation.
4. Practice medical charting for documenting patient assessment procedures.
5. Apply infection control guidelines and standards associated with equipment and procedures,
KEY TERMS
adventitious crepitus mucoid retractions
basilar decubitus (ulcer) mucopurulent rhonchi
bifurcation density nodule scoliosis
bronchoconstriction egophony paroxysmal (cough) serous
bronchodilation empyema patency stridor
bronchophony extrathoracic pectoriloquy symmetrical
bronchorrhea fetid pectus carinatum tenacious
bronchospasm flail pectus excavatum tetany
consolidation fremitus phonation Trendelenburg position
contralateral hyperinflation pleural effusion turbulent
copious hyperresonant pleural friction rub tympanitic
crackles (coarse) inspissated purulent wheal
crackles (fine) kyphosis rales wheezing
crepitation lordosis resonance whispered pectoriloquy
95
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Exercises
F Alcohol prep pads F MP3, CD, or cassette player
F Binaural stethoscopes (teaching models, if F Patient mannequin (or student)
available) F Recording of breath sounds
F DVD or video player and monitor F Video of physical assessment of the chest
F Human patient simulator
EXERCISE 7.1 PHYSICAL ASSESSMENT OF THE CHEST

EXERCISE 7 .1.1 IN S P ECTION
For you to perform a 1. Observe the “patient” for overall appearance, age, sex, and weight.
complete physical 2. Stand directly in front of the “patient” and observe the chest for the following:
assessment, the room should A. General shape and appearance (Fig. 7.1)
be well lit and the patient B. Anterior to posterior diameter
should ideally be naked to C. Sternal deformities
the waist. However, for i. Surgical or other scars
female patients the patient’s ii. Symmetrical expansion (Fig. 7.2): observe for any paradoxical or unequal
modesty must be considered expansion
and safeguarded. The patient iii. Presence of chest tubes
should be in the Fowler’s
position. Explain the process
and reassure the patient
before you perform the
assessment. Wash your
hands and apply standard
precautions and
transmission-based isolation
A B
C D E
Figure 7.1. Common abnormalities of the chest. (A) Funnel chest (pectus excavatum); (B) Pigeon breast (pectus carinatum); (C) Barrel
chest; (D) Kyphosis; (E) Scoliosis
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C H A P T E R 7 | PAT I E N T A S S E S S M E NT: ADVANC ED S K ILLS • 97
3. From the back of the “patient,” observe spinal curvature.
4. Observe skin for cyanosis, pallor, mottling, diaphoresis, swelling, bruises, and erythema.
5. Observe skin for any obvious masses, lesions, or nodules.
6. Assess the respiratory pattern. Look for regularity, accessory muscle use, rate and depth, and
patient positioning for breathing (Fig. 7.3).
7. Observe for retractions, pursed lip breathing, and nasal flaring.
A B
Figure 7.2. Normal and paradoxical motion.

(A) Normal inspiration; (B) Paradoxical
inspiration; (C) Normal expiration; and
(D) Paradoxical expiration. C D
Figure 7.3. The tripod position.
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EXERCISE 7 .1.2 PALPATION

1. Palpate the position of the trachea by inserting two fingers from the same hand on either side
of the trachea and moving your fingers downward (Fig. 7.4).
2. Palpate the skin for the presence of subcutaneous emphysema, which may be felt as crepitus
crackling under the skin (“Rice Krispies”).
3. Place your hands in the “butterfly” position with your thumbs on the spine and your
hands on the posterior rib margins. Palpate for equal bilateral expansion using the steps in
Figure 7.5.
4. Palpate the chest wall over each of the lung lobes for tactile fremitus as shown in Figure 7.6
while the “patient” says “ninety-nine.” Feel for any vibrations with the palms of your hands.
Avoid bony prominences.
5. Palpate for spinal curvature. Place two fingers from the same hand along either side of the
spine and move them downward, using sufficient pressure to cause skin blanching. Note any
deviations.
6. Assess peripheral perfusion by palpating pulses and capillary refill.
A B C
Figure 7.4. Palpating tracheal position.
Step 1 Step 2 Step 3
Figure 7.5. Palpation for chest excursion. (Adapted from Morton, PG: Health Assessment in Nursing, ed. 2. FA Davis, Philadelphia, 1993,
pp. 266–267, with permission.)
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Step 4 Step 5 Step 6
Figure 7.5.—cont'd
Figure 7.6. Palpating for tactile fremitus.

(From Morton, PG: Health Assessment in Nursing,
ed. 2. FA Davis, Philadelphia, 1993, p. 275, with
permission.)
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100 • LABOR ATO RY E XE RCI SE S F OR COM PE T E NC Y I N R E S P I R AT O RY C A R E
EXERCISE 7 .1.3 DIAGN OS TIC C HES T P E R C U S S I O N

Diagnostic chest percussion 1. Percuss over a solid structure such as the liver, thigh, or heart to create a dull percussion
may be performed by directly note.
striking the chest wall with a 2. Percuss over normal lung tissue to hear a resonant percussion note. Compare the sounds
finger between the ribs. It bilaterally.
may be performed indirectly 3. Percuss over the stomach to hear a hyperresonant or tympanitic percussion note.
by placing one hand on the 4. Estimate diaphragmatic excursion by first instructing the patient to take a full, deep breath.
chest wall and striking the Determine the lowest margin of resonance by percussing over the lower lung field and
middle or index finger with moving downward in small increments until a definite change in the percussion note is
your other hand, as shown in detected. Then instruct the “patient” to exhale maximally and hold this position while
Figure 7.7. As you percuss the percussion is repeated.
“patient,” compare bilateral 5. Record your findings on your laboratory report.
percussion notes for quality
and intensity. Table 7.1 shows
the important percussion
notes, location, and common
causes. Diaphragmatic
excursion can also be
estimated by percussion of
the posterior chest wall.1
Figure 7.7. Diagnostic chest percussion. (Adapted

from Morton, PG: Health Assessment in Nursing,
permission.)
Table 7.1 Percussion Sounds

SOUND QUALITY SOURCE
Resonant Hollow Normal lung
Dull Thudlike Liver, consolidated lung, pleural effusion
Hyperresonant/tympanitic Drumlike Hyperinflated lung (as in emphysema), gastric air bubble,
pneumothorax
Flat Flat Muscle, bone
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EXERCISE 7.2 AUSCULTATION
The stethoscope (Fig. 7.8) is 1. Listen to the breath sound tape (if available).
a valuable and essential 2. Auscultate your laboratory partner.
assessment tool for the RCP. A. Check your stethoscope for function. Wipe the earpieces and diaphragm with an alcohol
It consists of four basic swab. Place the earpieces securely in your ears. Turn the head of the stethoscope to the
parts: (a) a bell for low- diaphragm side and gently tap on it. If you do not hear anything, turn the chest piece
frequency sounds, such 180 degrees and repeat. Examine the chest piece and tubing regularly for cracks and
as heart sounds; (b) a other defects. Clean the earpieces of wax and dirt with an alcohol prep pad.
diaphragm for higher-pitched B. Warm the diaphragm piece with your hands.
lung sounds; (c) tubing, C. Instruct your “patient” to sit up, lean forward, and breathe through the mouth with the
which is ideally 11 to head turned away from you. Place the diaphragm lightly against the chest wall.
16 inches in length and thick D. Identify the location of normal breath sounds, as shown in Figure 7.9.
enough to exclude external
noise; and (d) binaural
earpieces.2 The RCP should
apply standard precautions
and transmission-based
isolation procedures as
appropriate.
Figure 7.8. Components of a stethoscope. (From

Morton, PG: Health Assessment in Nursing, ed. 2.
FA Davis, Philadelphia, 1993, p. 99, with permission.)
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E. Auscultate the posterior chest wall in at least six places, comparing sounds bilaterally, as
shown in Figure 7.10. You may proceed from apices to bases or from bases to apices as
long as you make bilateral comparisons.
F. Auscultate the anterior chest wall, with the “patient” leaning slightly back, in at least six
places. Compare sounds bilaterally.
Tracheal (bronchial) Tracheal (bronchial)

sounds sounds
Bronchovesicular
sounds Bronchovesicular
sounds
Vesicular Vesicular
sounds sounds
Figure 7.9. Location of normal breath sounds. (From Morton, PG: Health Assessment in Nursing, ed 2. FA Davis, Philadelphia, 1993, p. 270, with
permission.)
A B
Figure 7.10. Sequence for chest auscultation. (From Hogstel, MO and Keen-Payne, R: Practical Guide to Health Assessment Through the
Lifespan. FA Davis, Philadelphia, 1993, pp. 94–95, with permission.)
RE F E RE N CE S
1. Wilkins, RL, Dexter, JR, and Heuer, AJ: Clinical Assessment in Respiratory Care, ed. 6. Mosby, St. Louis, 2010, p. 80.
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C H A P T E R 7 | PAT I E N T A S S E S S M E N T: ADVANC ED S K ILLS • 103
Laboratory Report
CHAPTER 7: PATIENT ASSESSMENT: ADVANCED SKILLS
Name: Date:
Data Collection
EXERCISE 7.1 Physical Assessment of the Chest
E X E R C IS E 7. 1. 1 IN S P E C T IO N
Findings: ____________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
E X E R C IS E 7. 1. 2 PA L PAT IO N
Findings: ____________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
E X E R C IS E 7. 1. 3 D IA G N O S T IC CHEST PERCUSSION
Findings: ____________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
E X E R C IS E 7. 2 A U S C U LTAT IO N
Auscultate lab partner. Findings: _________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

1. You continue to evaluate Mr. C.O. Tu, who has a long-standing history of chronic obstructive pulmonary disease
(COPD). Recall that he has been brought to the emergency department (ED) by ambulance. He complains of increasing
shortness of breath and productive cough with thick, green sputum.
During physical examination of the chest, you notice a hyperresonant percussion note with decreased fremitus over
most of the lung fields except for the right lower lobe (RLL), which has a dull percussion note and increased fremitus.
A. Identify a possible explanation for these differences in your findings.
B. Based on your findings, describe what you would expect to hear on auscultation over the RLL.
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2. Bill Long, a 34-year-old man, presents to the ED with left-sided chest pain and shortness of breath. It is suspected that
he has a left-sided pneumothorax.
A. What findings on physical examination would help establish the diagnosis?
B. What diagnostic tests should be performed to confirm the diagnosis?
3. You are called to the ED to assess Maria Sanchez, who is 16 years old and is having an asthma attack. What might
you find upon physical examination?
4. Mrs. Phan is a patient on the long-term respiratory care unit and has a tracheostomy tube. The nurse asks you to
suction her. What patient assessment techniques should you perform in order to determine if the procedure needs to
be performed?
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STUDENT: DATE:
PHYSICAL ASSESSMENT OF THE CHEST
PERFORMANCE LEVEL
PERFORMANCE RATING
Performance Level:
NA = Not applicable
Performance Rating:


3. Observes patient for overall appearance, age, sex, and weight
4. Notes patient positioning (tripod, high Fowler’s, etc.)
5. Stands directly in front of the patient and observes chest for shape and appearance, anterior-posterior diameter, sternal deformities,
surgical or other scars, and symmetrical expansion
6. Observes for normal or abnormal spinal curvatures
7. Observes for any paradoxical or unequal expansion
8. Observes for retractions, pursed-lip breathing, nasal flaring, and abdominal paradox
9. Observes for presence of chest tubes
10. Observes the skin for cyanosis, pallor, mottling, diaphoresis, swelling, pitting edema, turgor, dryness, bruises, erythema, or petechiae
11. Observes skin for any masses, lesions, or nodules
12. Assesses respiratory pattern: regularity, rate and depth of breathing, and accessory muscle use
13. Evaluates for orthopnea, platypnea, pleurodynia
14. Palpates position of the trachea
15. Palpates skin for presence of subcutaneous emphysema
16. Palpates for bilateral chest expansion
17. Palpates chest wall for tactile fremitus
18. Palpates for spinal curvature
19. Palpates pulses and assesses capillary refill
20. Performs diagnostic chest percussion
21. Auscultates chest for normal, abnormal, and adventitious breath sounds (See PCE for Auscultation)
FOLLOW-UP
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PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch07_095-110.indd 106 07/02/13 4:43 PM


STUDENT: DATE:
AUSCULTATION
PERFORMANCE LEVEL
PERFORMANCE RATING
Evaluator: Setting:
Performance Level:
NA = Not applicable
Performance Rating:


3. Cleans earpieces, bell, and diaphragm of stethoscope with alcohol swab
4. Warms stethoscope diaphragm with hand
5. Places stethoscope in ears with earpieces facing forward into the ear canal
A. Verifies function by gently tapping on diaphragm with earpieces in place
6. Positions patient:
A. Has patient sit upright leaning forward (if possible), facing away
B. If patient is not able to sit up, gets assistance to turn patient to side to auscultate posterior chest
7. Auscultates the anterior chest in at least six positions, comparing sounds bilaterally
8. Auscultates the lateral chest bilaterally
9. Auscultates the posterior chest in at least six positions, comparing sounds bilaterally
10. Correctly interprets breath sounds
FOLLOW-UP
11. Properly identifies normal, abnormal, and adventitious breath sounds and their possible causes
2679_Ch07_095-110.indd 107 07/02/13 4:43 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
to modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch07_095-110.indd 108 07/02/13 4:43 PM


STUDENT: DATE:
COMMON PERFORMANCE ELEMENTS

PERFORMANCE LEVEL
PERFORMANCE RATING
Evaluator: Setting:
Performance Level:
NA = Not applicable
Performance Rating:

1. Verifies, interprets, and evaluates physician’s order or protocol
2. Scans chart for any other pertinent data and notes, including diagnosis, medications, therapies, and radiographic and other laboratory
results
3. Washes hands or applies disinfectant
4. Selects, obtains, assembles equipment correctly, verifies function
5. Troubleshoots equipment and corrects malfunctions if indicated
6. Applies personal protective equipment (PPE); observes standard precautions and transmission-based isolation procedures as
appropriate
7. Identifies patient, introduces self and department
8. Explains purpose of the procedure and confirms patient understanding

9. Positions patient for procedure
10. Assesses patient including, where applicable, vital signs, SpO2, breath sounds, and ventilatory status
FOLLOW-UP
11. Reassesses and reinstructs patient as needed
13. Maintains/processes equipment
14. Disposes of infectious waste and washes hands or applies disinfectant
15. Records pertinent data in chart and departmental records
16. Notifies appropriate personnel and makes any necessary recommendations or modifications to the patient care plan
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PERFORMANCE RATING:

COGNITIVE DOMAIN
to modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch07_095-110.indd 110 07/02/13 4:43 PM

Bedside
CHAPTER
Assessment
of Pulmonary
Mechanics
INTRODUCTION The respiratory care practitioner is often called to the bedside to obtain data relevant to
the state of the patient’s ability to breathe. Simple bedside measurements can be
performed. These data are essential in conjunction with clinical assessment and when
making decisions regarding initiation, modification, or discontinuance of respiratory
modalities and procedures, especially mechanical ventilation. Values obtained can also
be useful in making decisions regarding disease management.
These studies include, but are not limited to, the following parameters:
1. Tidal volume (VT), minute ventilation (VE), and alveolar ventilation (VA)
2. Maximum inspiratory pressure (MIP)
3. Maximum expiratory pressure (MEP)
4. Slow vital capacity (SVC)
5. Peak expiratory flow rate (PEFR)
OBJECTIVES 1. Perform bedside assessment of pulmonary mechanics in the laboratory and clinical settings.
Upon completion of this 2. Select, use, and maintain the equipment necessary to perform bedside assessment of pulmonary
chapter, you will be able to: mechanics, including vane and electronic respirometers.
3. Apply infection control guidelines and standards associated with each piece of equipment,
according to OSHA regulations, CDC guidelines, and American Thoracic Society (ATS)
standards.
4. Given a patient scenario, select the appropriate tests and relate the clinical significance of the
measured parameters to treatment decisions.
5. Explain alternative ways of obtaining data when dealing with patients with limited mental or
functional capacity or language barriers.
6. Practice communication skills needed to instruct patients in the performance of pulmonary
mechanics testing.
7. Practice medical charting for documenting performance of bedside pulmonary mechanics
procedures.
KEY TERMS
atmospheric temperature compliance lumen
and pressure, saturated dead space resistance
(ATPS) elastance spirometer
body temperature and facilitate transducer
pressure, saturated flow rate turbulent
(BTPS) laminar vane
111
2679_Ch08_111-122.indd 111 07/02/13 4:43 PM

Exercises
F Briggs adaptors F Masks
F BTPS conversion chart F Nose clips
F Corrugated tubing F One-way valves
F Disposable gloves F Peak flowmeters (disposable or permanent)
F Disposable mouthpieces F Predicted values nomograms
F Electronic and vane respirometers F Pressure manometer with positive and nega-
F Human patient simulator mannequin tive ranges
(if available) F Watch with a second hand
F Inspiratory force adaptors (disposable)
F Intubated or tracheostomized airway manage-
ment trainer
These exercises will require you to work in groups of two. You may carry out all the exercises
with the same partner, or the instructor may want to change pairs to enhance each student’s abil-
ity to communicate and explain the procedure to a different person.
In an actual clinical situation, the patient may be receiving supplemental oxygen via mask or may
be on a ventilator. To obtain bedside pulmonary mechanics, the patient would have to be re-
moved from these devices and an alternative mode of oxygen delivery instituted. In these circum-
stances, the practitioner should monitor the patient carefully for signs of hypoxia while the pa-
rameters are being obtained. This includes observation of the patient, use of pulse oximetry, and
cardiac monitors. Placing the patient on a nasal cannula may be one alternative. The therapist
should consult with the physician or follow departmental policies under these circumstances. If
the patient is on a ventilator, the practitioner must ensure that the ventilator connector is handled
aseptically. The ventilator alarms may need to be temporarily bypassed, but the practitioner must
ensure that they are reset and functional once the procedure is concluded. The patient must be
immediately returned to the ventilator if there is any indication that the patient is not tolerating
the testing. Results of the testing may be interpreted based on normal and critical values, shown
in Table 8.1.
Table 8.1 Normal and Critical

PARAMETER NORMAL VALUE MINIMAL ACCEPTABLE VALUE
Values for Bedside Spirometry
Tidal volume 5–8 mL/kg —
Vital capacity 50–70 mL/kg 10–15 mL/kg
Minute ventilation 6–10 Lpm —
Peak Flow 300–600 Lpm 80–100 Lpm
Negative Inspiratory Force –60 TO –100 cm H2O –20 cm H2O
Maximum Expiratory Pressure +60 TO +100 cm H2O +20 cm H2O
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C H A P T E R 8 | B E D S I D E A S S E S S M E N T O F P U LM ONARY M EC HANIC S • 113
EXERCISE 8.1 OBTAINING VT, VE, AND VA
This exercise requires you to obtain data using a device called a respirometer. The two major
types of respirometers are rotating vane spirometers, as shown in Figure 8.1, and electronic
respirometers, as shown in Figure 8.2.
1. Gather the necessary equipment, which includes a watch with a second hand, spirometer,
disposable nose clips, mouthpieces, one-way valves, and tubing to prevent cross contamina-
tion with the spirometer.
2. Use a one-way valve each time this procedure is performed. The one-way valve is for single-
patient use only.
3. Wash hands and apply standard precautions and transmission-based isolation procedures as
appropriate.
4. Assemble the equipment as shown in Figure 8.3.
A. Attach a single length of large-bore corrugated tubing to the T-piece opening. Attach
the mouthpiece to the opposite end of the corrugated tubing.
B. Attach a single length of corrugated tubing to the expiratory side of the T-piece one-
way valve assembly.
C. Attach the respirometer to the corrugated tubing using a 22-mm outer diameter
(OD)/15-mm inner diameter (ID)adaptor.
D. Verify the appropriate direction of flow by ensuring that one-way valves allow for
inspiration from the room and expiration into the respirometer.
5. Introduce yourself. Record your partner’s age, sex, height, and weight on your laboratory
report.
6. Explain the procedure and the purpose of the testing to your partner. Demonstrate if
necessary.
7. Instruct your partner to put the mouthpiece into his or her mouth. Emphasize the impor-
tance of maintaining a tight seal around the mouthpiece. Explain the purpose of using the
nose clips.
8. Allow your partner to stabilize, or get used to, breathing through the mouthpiece and
respirometer.
9. Turn the respirometer on. Activate the respirometer by pressing the “Reset” button to zero
on the dial, and begin recording your partner’s exhaled volumes.
10. Simultaneously, count your partner’s breath rate.
11. Measure these parameters for one full minute. At the end of precisely one minute, press the
“Stop” or “Off” button to stop the recording and preserve the data.
12. Record the data on your laboratory report. Record the room temperature. Look up the con-
version factor for that room temperature. Convert to BTPS.
13. Disassemble and properly clean the equipment.
A. In the event that multiple measurements are required on an individual patient, the
one-way valve assembly may be aseptically stored in the patient’s room. Otherwise,
the assembly should be discarded after use.
B. The respirometer should be wiped down with a 70% isopropyl alcohol solution
between patients.
C. You should sterilize the respirometer between patients if it will be used for patients
with active tuberculosis or any other disorder requiring airborne or droplet isolation
precautions.
Figure 8.2. Electronic ultrasonic vortex flow-

sensing respirometer. (Courtesy of Cardinal Health,
Figure 8.1. A vane respirometer. Dublin, OH.)
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114 • LABORATORY E XE RCI SE S F OR COM PE T E NC Y I N R E S P I R AT O RY C A R E
Figure 8.3. Assembly of one-way valve

monitoring circuit.
EXERCISE 8.2 OBTAINING NEGATIVE INSPIRATORY FORCE AND MAXIMUM

EXPIRATORY PRESSURE
1. Gather the necessary equipment: mask or mouthpiece and nose clips, disposable inspiratory
force adaptor with one-way valve, and pressure manometer.
2. Wash your hands and apply standard precautions and transmission-based isolation
3. Assemble the equipment as shown in Figure 8.4.
A. Attach the small-bore tubing to the nipple on the inspiratory force meter.
B. Attach the opposite end of the small-bore tubing to the inspiratory force adaptor or the
port on the one-way valve setup.
C. The inspiratory force adaptor will fit directly onto an endotracheal or tracheostomy
tube. For nonintubated patients, attach the adaptor to a mask or mouthpiece.
D. Explain the procedure to your partner. Demonstrate if necessary.
E. Completely occlude the opening on the inspiratory force adaptor with your finger and
instruct your partner to inhale as hard as possible from the normal resting exhalation
position. No occlusion is needed if you use the one-way valve. Note the maximum
negative pressure achieved.
F. Repeat the procedure two more times.
G. Record the data from the three trials on your laboratory report.
Figure 8.4. Assembled equipment for

inspiratory force measurement.
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C H A P T E R 8 | B E D S I D E A S S E S S M E N T O F P U LM ONARY M EC HANIC S • 115
4. Using the same equipment, completely occlude the opening of the adaptor and instruct your
partner to take a deep breath and then to exhale as strongly as possible.
A. Repeat the procedure two more times.
B. Record the data from the three trials on your laboratory report.
EXERCISE 8.3 OBTAINING A SLOW VITAL CAPACITY
NOTE: If a vane-type respirometer, such as a Wright respirometer, is used, high flow rates will
warp the vanes. Do not perform a forced vital capacity (FVC) with this device!
1. Gather and assemble the necessary equipment: respirometer, one-way valves, mouthpiece or
mask, and nose clips as in Exercise 8.1.
appropriate.
3. Turn the respirometer on and reset to zero.
4. Explain the procedure by instructing your partner to take in the deepest breath possible and
then exhale slowly and completely into the spirometer. Demonstrate if necessary.
5. Ensure a tight seal by making sure that the mouthpiece is secure, that nose clips are in place,
or, if using a mask, that there are no leaks.
6. Coach the “patient” throughout the procedure. Turn off the respirometer or press the “Stop”
button when exhalation is complete.
7. Repeat the procedure two more times and record the data on your laboratory report.
Convert values to BTPS.
EXERCISE 8.4 OBTAINING PEAK EXPIRATORY FLOW RATE MEASUREMENTS

1. Obtain a peak flowmeter and a mouthpiece (Fig. 8.5). The use of nose clips is recommended.
appropriate.
3. Instruct your partner to take in a deep breath and then to blow as strongly as possible into
the peak flowmeter. Ensure a tight seal. Exhalation down to residual volume is not necessary.
Demonstrate if necessary.
4. Repeat the procedure two more times and record the data on your laboratory report.
Convert values to BTPS.
Scale (LPM)
Red
indicator
Figure 8.5. Peak flowmeter. (Adapted from

HealthScan Products, Inc., Cedar Grove, NJ.) Mouthpiece
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EXERCISE 8.5 OBTAINING DATA ON PATIENTS WITH ARTIFICIAL AIRWAYS

1. Obtain one-way valves, corrugated tubing, and Briggs adaptors.
2. Assemble the equipment as previously described.
4. Attach equipment to the adaptor of the artificial airway as shown in Figure 8.6.
5. If you are using a human patient simulator mannequin, measure the VE and f and calculate
the VT. Record this information on your laboratory report.
Figure 8.6. Attaching monitoring equipment to an

artificial airway.
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C H A P T E R 8 | B E D S I D E A S S E S S M E N T O F P U LMONARY M EC HANIC S • 117
Laboratory Report
CHAPTER 8: BEDSIDE ASSESSMENT OF PULMONARY MECHANICS
Name: Date:
Data Collection
Laboratory partner(s): __________________________________________________________________________________________
Age: Sex: Height: Weight: Race:
Calculate ideal body weight. Show your work.
EXERCISE 8.1 Obtaining VT, VE, and VA
VE: Breath rate: Room temperature: °F
Calculate your partner’s average tidal volume using the following formula: VT = VE/f. Don’t forget the proper units! Show your work.
VT =
Calculate your partner’s alveolar ventilation using the formula: VA = (VT – VD) f. Don’t forget the proper units! Show your work.
VD =
VA =
Conversion factor for room temperature =
Convert VE to BTPS. Show your work.
BTPS =
Convert VT to BTPS. Show your work.
BTPS =
EXERCISE 8.2 Obtaining Negative Inspiratory Force and Maximum Expiratory Pressure
Trial 1 Trial 2 Trial 3

MIP
MEP
Circle the value to be reported.
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EXERCISE 8.3 Obtaining a Slow Vital Capacity

SVC (ATPS)
SVC (BTPS)
Convert to BTPS. Show your work.
BTPS = _______
EXERCISE 8.4 Obtaining Peak Expiratory Flow Rate Measurements

PEFR
EXERCISE 8.5 Obtaining Data on Patients with Artificial Airways
VE: Breath rate: Room temperature: °F
Calculate average VT. Show your work.
VT =
Convert to BTPS correction factor. Show your work.
VE (BTPS) =
VT (BTPS) =

1. Calculate the missing values. Show your work.
Weight 200 lb 60 kg 140 lb

VT 400 mL
f 14 20 15
VE 12.6 L
VD
VA 6.0 L
2. Why is it necessary to obtain at least three trials? Which trial(s) would you report to the physician?
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3. Which measurement(s) required the most cooperation from your partner to obtain results?
4. Dr. Shah asks you to perform a bedside evaluation on Mrs. Hernandez, a 29-year-old, 150-lb woman admitted with a
diagnosis of myasthenia gravis. As you begin to explain the procedure, you realize that she speaks and understands
only Spanish.
A. How would you alter your instructions or actions to the patient to obtain the data under these circumstances?
B. What is the clinical significance of monitoring these parameters in a patient with Mrs. Hernandez’s condition?
5. You are able to obtain the following parameters:
VT: 300 mL f: 25/min
VE: 7.7 Lpm MIP: –40 cm H2O
SVC: 1.5 Lpm PEFR: 200 Lpm
A. For each of these parameters, indicate whether it is within normal limits, abnormal, or a critical value.
B. What is your overall impression and interpretation of these results?
C. What would be your recommendations to the physician regarding evaluation and treatment of this patient?
D. Which of these parameters is indicative of the patient’s ability to cough and deep breathe?
E. Which of these parameters is most indicative of respiratory muscle strength?
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6. Dr. Shah now tells you that she suspects that Mrs. Hernandez has diplococcal pneumonia.
A. What infection control procedures related to the patient, the equipment, and yourself did you practice to ensure
that the infection would not be spread to you or to other patients?
B. What, if any, additional procedures would you follow if Mrs. Hernandez was suspected of having tuberculosis?
7. Two hours later, the bedside evaluation is repeated and the following data are obtained: VT 200 mL; f 40/minute.
Based on these data, which of the following would most likely be increased above normal? Circle as many as are
appropriate.
A. VE
B. VA
C. VD
D. PaCO2
8. In a patient with an artificial airway, which test(s), if any, could not be performed?
9. Which parameters cannot be obtained in a comatose patient?
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STUDENT: DATE:
BEDSIDE PULMONARY MECHANICS
PERFORMANCE LEVEL
PERFORMANCE RATING
Performance Level:
NA = Not applicable
Performance Rating:
Two or more errors of commission or omission of mandatory or essential performance elements will terminate the
procedure, and require additional practice and/or remediation and reevaluation. Student is responsible for obtaining
additional evaluation forms as needed from the Director of Clinical Education (DCE).

2. Obtains all mouthpieces, one-way valve, and disposable adapters for equipment

4. Uses nose clips or mask if needed
A. Obtains required parameters:
B. Minute volume, f
C. VT (computed)
D. RSBI (computed)
E. SVC or FVC (forced expiration should not be performed with handheld vane-type respirometer)
5. Repeats the following at least three times for best result:
A. SVC
B. NIF/MIP
C. PEFR
6. Performs MVV for 12–15 seconds and extrapolates for liters per minute; ensures the patient is sitting upright
FOLLOW-UP
7. Common Performance Elements Steps 11–16
8. Records best effort for each value
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PERFORMANCE RATING:

COGNITIVE DOMAIN
to modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
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CHAPTER Oxygen Supply
Systems
INTRODUCTION Most respiratory therapy devices require some type of pressurized gas source. Gas
source systems include cylinders, piped systems, and bulk gas and liquid systems.
Because your primary responsibility as a respiratory care practitioner is the
administration of medical gases, your thorough understanding of the principles of
medical gas therapy and its delivery is necessary for safe patient care.1 To illustrate this
point, in an issue of Respiratory Care Manager, a critical incident was reported in which
oxygen was contaminated with trichloroethylene, a toxic substance, which may have
contributed to the deaths of five patients.2 Although you may have an advanced
comprehension of pathophysiology and the goals of medical gas therapy, you must
also have a sound working knowledge of the capabilities and safe handling of the related
equipment. If these systems fail, your in-depth knowledge of oxygen supply systems
would enable a quick and effective response.1
OBJECTIVES 1. Identify the contents of medical gas cylinders.

Upon completion of this 2. Identify the markings on a medical gas cylinder as defined by the Department of
chapter, you will be able to: Transportation (DOT).
3. Differentiate between the American Standard Safety System (ASSS) index for large cylinders,
the Diameter Index Safety System (DISS), and the Pin Index Safety System (PISS) for small
cylinders.
4. Demonstrate the safe handling, transport, and storage of medical gas cylinders.
5. Identify the components of a bulk liquid system.
6. Identify the components of a reserve system.
7. Operate and troubleshoot an air compressor.
8. Identify the components of a single-stage and a multistage regulator.
9. Identify the components of a Bourdon gauge regulator.
10. Identify the components of a Thorpe tube flowmeter.
11. Differentiate between a pressure-compensated and a non–pressure-compensated flowmeter.
12. Calculate the duration of flow of a cylinder.
13. Set up and safely operate a blender.
14. Locate and identify zone valves in a health-care facility.
15. Identify and safely use wall outlet quick-connect systems.
123
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KEY TERMS
ambient density melting point regulator
American Standard Diameter Index Safety Pin Index Safety reservoir
Safety System (ASSS) System (DISS) System (PISS) specific gravity
boiling point evaporation pounds per square inch sublimation
combustible flammable (psi) The Joint Commission
compensation fractional distillation pounds per square inch (TJC)
critical pressure frangible gauge (psig) volatile
critical temperature fusible reducing valve
Exercises
F Adjustable wrenches F Liter metering devices
F Air compressor F Samples of quick-connect adaptors and wall
F Blender plates
F Bourdon gauge regulators F Sample of wall outlet box and components
F Cylinder trucks and circle stands F Single-stage and multistage regulators
F E cylinder keys F Screwdrivers: flat head and Phillips, Allen
F Gasloc® seals (PISS cylinder washers) wrenches
F High-pressure air and oxygen hoses with F Stopwatch
DISS connectors and quick-connect types F Thorpe tube flowmeters, with and without
F H- and E-sized oxygen and other types of regulators
medical gas cylinders F Torx wrench
EXERCISE 9.1 MEDICAL GAS CYLINDERS

EXERCISE 9 .1 .1 S AF E STORAGE OF C Y LI N D E R S — D I A G R A M
Carefully observe the diagram shown in Figure 9.1 and identify at least four cylinder storage
safety violations. Record your list on your laboratory report.
Figure 9.1. Scene survey.
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C H A P T E R 9 | O X Y G EN S UP P LY S Y S TEM S • 125
EXER C ISE 9.1.2 SAFE S T O R A G E O F C Y LI N D E R S

In this exercise, the instructor has prepared a scenario in which medical gas cylinders are being
stored improperly. Carefully observe the area. Identify and correct the safety violations (at least
four are present). Record each safety violation observed and corrective actions taken on your
laboratory report.
EXER C ISE 9.1.3 SAFE H A N D LI N G A N D T R A N S P O R T O F C Y LI N D E R S

1. Wheel an H cylinder on its truck (Fig. 9.2) from one side of the laboratory to the other. Be
sure to push, not pull.
2. Take the H cylinder off of its truck. Carefully walk it across the room and safely secure it in
a circle stand (donut) or other type of cylinder stand (see Fig. 9.2).
3. Repeat steps 1 and 2 for an E cylinder.
EXER C ISE 9.1.4 CYLIN DER MA R K I N G S

Your instructor will supply you with two different types and sizes of medical gas cylinders.
Observe the cylinder markings, as shown in Figure 9.3. Record the following data on your
laboratory report:
Size of each cylinder Contents of each cylinder
Safety system of each cylinder outlet Date of manufacture of each cylinder
Retest date of each cylinder Ownership of each cylinder
Serial number Filling pressure
EXER C ISE 9.1.5 SAFETY S Y S T E M C O N N E C T I O N S

1. Obtain an H cylinder with a regulator and an E cylinder with a regulator. Observe the gas
outlets and points of regulator attachments. Differentiate between the American Standard
Safety System (ASSS), the Diameter Index Safety System (DISS), and the Pin Index Safety
Figure 9.2. (A) H cylinder and truck; (B) Circle

stand. A B
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2 88 EE 189
DOT 3AA 2265
H–282755 3 93
DJG 5 03
4 13
G
Figure 9.3. Location of cylinder markings. Front Back
A
D B
Figure 9.4. Identification of safety systems.
System (PISS). Identify the safety systems shown in Figure 9.4. Record the corresponding
letter from the diagram next to its component on your laboratory report:
Post
Threaded ASSS outlet
Valve stem
DISS
PISS
2. Using the H cylinder, identify the location of the frangible disk or fusible plug pressure relief
valves on the valve stem. Record the corresponding letter from Figure 9.4 next to its
component on your laboratory report.
EXERCISE 9.2 REDUCING VALVES, REGULATORS, AND FLOWMETERS

EXERCISE 9 .2 .1 R EDUCIN G VALV ES
1. Use the following list to identify the labeled parts of the reducing valve shown in Figure 9.5
and record the components on your laboratory report:
ASSS high-pressure inlet
DISS gas outlet
Bourdon gauge pressure manometer
Bourdon gauge flowmeter
Bourdon gauge flow control
pressure relief valve(s)
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E C
B A
Figure 9.5. Components of a reducing

valve. D
2. Determine whether the regulator is a single-stage or multistage regulator. Record your

observation on your laboratory report.
3. Determine whether the reducing valve is adjustable or preset. Record your observation on
your laboratory report.
4. Announce out loud that you are about to “crack” a cylinder. Make sure that no one is facing
the gas outlet while this is being done. “Crack” the cylinder by quickly opening and closing
the main valve so that a brief blast of gas is released. Then attach the regulator to the
cylinder. Turn on the cylinder and record the pressure on your laboratory report.
EXER C ISE 9.2.2 BOUR DO N G A U G E R E G U LAT O R

1. Use the following list to identify the labeled parts of a Bourdon gauge regulator shown in
Figure 9.6 and record the components on your laboratory report.
high-pressure inlet Bourdon gauge flow control
gas outlet (oxygen nipple adapter) T-valve
Bourdon gauge pressure manometer PISS yoke
Bourdon gauge flowmeter PISS pins
pressure relief valve(s) Gasloc® seal (O-ring or washer)
D
E
H
A J
C
Figure 9.6. Components of a Bourdon gauge regulator.
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A. Attach the Bourdon gauge regulator to an H or E cylinder, as available.
B. Turn on the cylinder completely. Record the pressure on your laboratory report.
C. Turn the flow to 5 Lpm. Occlude the orifice with your finger. Record your observations
2. Obtain an E cylinder with a Bourdon gauge regulator. Turn the flowmeter on to 3 Lpm.
Lay the cylinder on its side and observe the flowmeter gauge reading. Record this on your
laboratory report.
3. Obtain an E cylinder. Replace the Gasloc® seal (washer) on the regulator and reattach it.
If an H cylinder was used for step 2, set the Bourdon gauge flowmeter on this E cylinder to
5 Lpm. Record the pressure on your laboratory report.
4. Turn the flowmeter off. Turn the regulator off. “Bleed” the pressure from the regulator by
turning the flowmeter on until the pressure gauge returns to zero. Turn the flowmeter off.
EXERCISE 9 .2.3 THOR P E TUBE F LOW ME T E R S

1. Use the following list to identify the labeled parts of a Thorpe tube flowmeter shown in
DISS or quick-connect high-pressure gas inlet
DISS gas outlet
Thorpe tube
flowmeter needle valve control knob
PTO (pressure take-off) 50-psi outlet
2. Attach a Thorpe tube flowmeter with a regulator to an H cylinder. Turn the cylinder on.
Record the pressure and your observations on your laboratory report.
3. Turn the flow up to 8 Lpm. Completely occlude the orifice with your finger. Record your
observations on your laboratory report.
4. Obtain an E cylinder with a regulator with a Thorpe tube flowmeter. Turn the flowmeter on
to 3 Lpm. Lay the cylinder on its side and observe the flowmeter gauge reading. Record this
on your laboratory report and contrast this with what happened with the Bourdon gauge
regulator in the previous Exercise 9.2.2.
5. Turn the flowmeter off. Turn the regulator off. “Bleed” the pressure from the regulator by
turning the flowmeter on until the pressure gauge returns to zero. Turn the flowmeter off.
D
A
Figure 9.7. Components of a Thorpe tube

flowmeter. E
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EXER C ISE 9.2.4 CALCULAT I O N O F C Y LI N D E R D U R AT I O N

For the pressures and flows recorded in Exercises 9.2.2 and 9.2.3, calculate the duration of flow
for the E and H cylinders using the following formula and the appropriate conversion factor from
Table 9.1.
Duration of flow = Pressure in cylinder × Cylinder conversion factor / Flow rate

Remember, this will give you the duration of flow in minutes. You must divide by 60 to obtain
duration in hours and multiply any decimal remainder by 60 to obtain minutes. Show your work.
Table 9.1 Cylinder Conversion

Cylinder Size Conversion Factor
Factors
D 0.16
E 0.28
G 2.41
H or K 3.14
EXERCISE 9.3 AIR COMPRESSORS
1. Identify the following components of an air compressor, as shown in Figure 9.8. Record the
labeled parts on your laboratory report.
electrical cord
pressure outlets
pressure manometer
pressure adjustment
filter
2. Turn on the compressor and start timing with the stopwatch. What is the operating pressure
of the device? How long did it take the compressor to achieve the operating pressure? Record
the pressure and time on your laboratory report.
Figure 9.8. Components of an air compressor. A
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EXERCISE 9.4 BLENDERS
1. Use the following list to identify the labeled parts of an air/oxygen blender shown in
air inlet
oxygen inlet
gas outlet
alarm
Fio2 adjustment control
2. Connect the pressure hoses to the appropriate connections. Identify the safety system. Turn
on the gas supplies. Adjust the Fio2 to 0.40. Record your observations, if any, on your
laboratory report.
3. Disconnect the air pressure hose. Record your observations on your laboratory report.
4. Reattach the air hose. Disconnect the oxygen hose. Record your observations on your
laboratory report.
5. Reattach the oxygen hose.
6. Attach a flowmeter to the blender outlet. Adjust the blender to 60%. Turn the flow to 8
Lpm. Analyze the blender output. Record the measured FIO2 on your laboratory report.
Figure 9.9. Components of an air/oxygen blender. (Adapted B

from Bird Products Corporation, Palm Springs, CA.) A
EXERCISE 9.5 BULK STORAGE SYSTEMS

EXERCISE 9 .5.1 L IQUID STORAGE S Y S T E M
1. Use the following list to identify the labeled parts of the liquid bulk storage system shown in
liquid container: carbon steel-protected outer shell
gas vent valve
vaporizer panels
control panel
main line to hospital
EXERCISE 9 .5.2 BAN K AN D RES ERVE S Y S T E MS

1. Use the following list to identify the labeled parts of a bank system shown in Figure 9.11 and
record the labeled parts on your laboratory report.
gas cylinders
connecting pipes
main-line pressure alarm
bank manometers
main supply line
switch-over
check valves
main supply manometer
2679_Ch09_123-144.indd 130 07/02/13 4:43 PM

D
E
C
A
Figure 9.10. Components of a bulk liquid oxygen
system.
H A
B
D
E G
Figure 9.11. Components of a bank C

system.
EXERCISE 9.6 ZONE VALVES AND WALL OUTLETS
You may need to perform 1. Locate the two zone valves (Fig. 9.12) (in the health-care facility, if not available in the lab).
this exercise in the clinical Determine which rooms or units would be affected by shutting off these valves. Observe the line
setting because of the pressures for air, oxygen, and vacuum. Record the pressures for each on your laboratory report.
lack of availability of the 2. Locate a wall outlet (Fig. 9.13) at your institution. Identify the type of quick-connect used
necessary equipment in (Fig. 9.14) and record this on your laboratory report.
the laboratory. 3. Obtain a flowmeter with the same type of connection. Practice engaging and disengaging the
flowmeter. Record your observations on your laboratory report. If different types are used,
compare and contrast the ease of use.
4. Unscrew the faceplate of a sample wall outlet. (Make sure the compressed gas system is
turned off if a functional outlet is used.) Take notice of the locking mechanism that holds the
flowmeter in place. Take the mechanism apart. Examine the O-rings that prevent leakage for
cracks or pitting. Replace if needed. Reassemble and replace when finished.
2679_Ch09_123-144.indd 131 07/02/13 4:43 PM

Figure 9.12. Zone valve.
Figure 9.13. Wall outlets.
Figure 9.14. Types of wall outlet quick-connect

systems. (A) Oxyquip '07 O.E.S.; (B) Schrader;
(C) Ohmeda; (D) Chemetron; (E) Puritan Bennett. E
RE F E RE N CE S
1. Cairo, SM, and Pilbeam, SP: Respiratory Care Equipment, ed. 8. Mosby, St Louis, 2010, p. 60.
2. Tainted O2 linked to ICU deaths. Respiratory Care Manager 5:4, 1996.
2679_Ch09_123-144.indd 132 07/02/13 4:43 PM

Laboratory Report
CHAPTER 9: OXYGEN SUPPLY SYSTEMS
Name: Date:
Data Collection
EXERCISE 9.1 Medical Gas Cylinders
E X E R C IS E 9. 1. 1 S A F E S T O R A GE OF CYL IN DERS—DIAGRAM
1. __________________________________________________________________________________________________________
2. __________________________________________________________________________________________________________
3. __________________________________________________________________________________________________________
4. __________________________________________________________________________________________________________
5. __________________________________________________________________________________________________________
E X E R C IS E 9. 1. 2 S A F E S T O R A GE OF CYL IN DERS
Identify the safety violations and corrective actions taken:
1. __________________________________________________________________________________________________________
2. __________________________________________________________________________________________________________
3. __________________________________________________________________________________________________________
4. __________________________________________________________________________________________________________
5. __________________________________________________________________________________________________________
2679_Ch09_123-144.indd 133 07/02/13 4:43 PM

E XE RCI SE 9 .1 .4 C Y LIN D E R MA R K IN G S
Cylinder A Cylinder B
Size
Contents
Safety system
Date of manufacture
Retest date
Ownership
Serial number
Filling pressure
E XE RCI SE 9 .1 .5 S A F E T Y S Y S T E M C O N NE C T ION S
Identify the corresponding letter from Figure 9.4:
ASSS: ______________________________________________________________________________________________________
DISS: _______________________________________________________________________________________________________
PISS: _______________________________________________________________________________________________________
Pressure-relief valve(s): ________________________________________________________________________________________
EXERCISE 9.2 Reducing Valves, Regulators, and Flowmeters
E XE RCI SE 9 .2 .1 R E D U C ING VA LV E S
A. __________________________________________________________________________________________________________
B. __________________________________________________________________________________________________________
C. __________________________________________________________________________________________________________
D. __________________________________________________________________________________________________________
E. __________________________________________________________________________________________________________
F. __________________________________________________________________________________________________________
Single or multistage? __________________________________________________________________________________________
Adjustable or preset? __________________________________________________________________________________________
Pressure recorded: ____________________________________________________________________________________________
2679_Ch09_123-144.indd 134 07/02/13 4:43 PM

E X E R C IS E 9. 2. 2 B O U R D O N G AUGE REGUL ATOR
A. __________________________________________________________________________________________________________
B. __________________________________________________________________________________________________________
C. __________________________________________________________________________________________________________
D. __________________________________________________________________________________________________________
E. __________________________________________________________________________________________________________
F. __________________________________________________________________________________________________________
G. __________________________________________________________________________________________________________
H. __________________________________________________________________________________________________________
I. __________________________________________________________________________________________________________
J. __________________________________________________________________________________________________________
Pressure in the cylinder: _______________________________________________________________________________________
What occurred when you occluded the orifice of the Bourdon gauge? ___________________________________________________
____________________________________________________________________________________________________________
What occurred to the readings when the tank was laid on its side? ______________________________________________________
E cylinder pressure: ___________________________________________________________________________________________
E X E R C IS E 9. 2. 3 T H O R P E T U B E F L OW METERS
A. __________________________________________________________________________________________________________
B. __________________________________________________________________________________________________________
C. __________________________________________________________________________________________________________
D. __________________________________________________________________________________________________________
E. __________________________________________________________________________________________________________
F. __________________________________________________________________________________________________________
Pressure in the cylinder: _______________________________________________________________________________________
What occurred immediately when the cylinder was turned on? _________________________________________________________
____________________________________________________________________________________________________________
What happened when you occluded the outlet of the Thorpe tube flowmeter? _____________________________________________
What happened to the readings when the tank was laid on its side? _____________________________________________________
E X E R C IS E 9. 2. 4 C A L C U L AT IO N OF CYL IN DER DURATION
Show your work.
Duration of E cylinder: _________________________________________________________________________________________
Duration of H cylinder: _________________________________________________________________________________________
2679_Ch09_123-144.indd 135 07/02/13 4:43 PM

EXERCISE 9.3 Air Compressors
A. __________________________________________________________________________________________________________
B. __________________________________________________________________________________________________________
C. __________________________________________________________________________________________________________
D. __________________________________________________________________________________________________________
E. __________________________________________________________________________________________________________
F. __________________________________________________________________________________________________________
Compressor operating pressure reading: ___________________________________________________________________________
Time until operating pressure: ___________________________________________________________________________________
EXERCISE 9.4 Blenders
A. __________________________________________________________________________________________________________
B. __________________________________________________________________________________________________________
C. __________________________________________________________________________________________________________
D. __________________________________________________________________________________________________________
E. __________________________________________________________________________________________________________
Analyzed FIO2: ________________________________________________________________________________________________
Observations:_________________________________________________________________________________________________
____________________________________________________________________________________________________________
EXERCISE 9.5 Bulk Storage Systems
E XE RCI SE 9 .5 .1 L IQ U ID S T O R A G E S Y S T E M S
A. __________________________________________________________________________________________________________
B. __________________________________________________________________________________________________________
C. __________________________________________________________________________________________________________
D. __________________________________________________________________________________________________________
E. __________________________________________________________________________________________________________
E XE RCI SE 9 .5 .2 B A N K A ND R E S E R V E S Y S T E MS
A. __________________________________________________________________________________________________________
B. __________________________________________________________________________________________________________
C. __________________________________________________________________________________________________________
D. __________________________________________________________________________________________________________
E. __________________________________________________________________________________________________________
F. __________________________________________________________________________________________________________
G. __________________________________________________________________________________________________________
H. __________________________________________________________________________________________________________
2679_Ch09_123-144.indd 136 07/02/13 4:43 PM

EXERCISE 9.6 Zone Valves and Wall Outlets
Location of zone valves and areas controlled by each: ________________________________________________________________
____________________________________________________________________________________________________________
Oxygen line pressure: __________________________________________________________________________________________
Air line pressure: _____________________________________________________________________________________________
Vacuum line pressure: _________________________________________________________________________________________
Type of wall outlet quick connects: _______________________________________________________________________________
Observations: ________________________________________________________________________________________________

1. Why is it necessary to “crack” a cylinder before attaching a regulator?
2. What is the benefit to using a multistage reducing valve versus a single-stage reducing valve?
3. Identify at least three ways to determine whether a flowmeter is compensated.
4. Which would be preferred to transport a patient on a stretcher, a Bourdon gauge flowmeter or a Thorpe tube
flowmeter? Explain why.
5. What would be the preferred method to transport a patient in a wheelchair with a tank carrier attached? Why?
2679_Ch09_123-144.indd 137 07/02/13 4:43 PM

6. Identify the following [flammability must be categorized as “flammable” (F), “nonflammable” (NF), or “supports
combustion” (SC)]:
Symbol Gas Color Code Combustion

O2
O2 + N2
CO2
CO2 /O2
N2
He
He/O2
N2O
NO
(CH2)3
ETO
7. Mr. Butinsky is using a nasal cannula at 3 Lpm. The nurse calls you and tells you that the patient must go to x-ray in a
wheelchair. Describe the specific equipment required to transport this patient to x-ray.
8. Why is the piping for gas supply systems in hospitals organized into zones?
9. You are a respiratory therapist caring for a patient who must go on an external transport to another hospital that is
approximately 2 hours away. The patient is on a 4-Lpm nasal cannula. Upon setting up the oxygen E cylinder, you
note that the tank pressure is 2,000 psi. Calculate the duration of flow and give all necessary recommendations for the
transport. Show your work.
10. A nurse calls you to the NICU because the alarm is sounding on an oxygen blender. What might be the problem and
how should it be remedied?
2679_Ch09_123-144.indd 138 07/02/13 4:43 PM


STUDENT: DATE:
BULK MEDICAL GAS SUPPLY SYSTEM

PERFORMANCE LEVEL
PERFORMANCE RATING
Evaluator: Setting:
Performance Level:
NA = Not applicable
Performance Rating:
LIQUID BULK SYSTEMS

1. Identifies the liquid gas container
2. Identifies gas vent valve
3. Identifies vaporizer panels
4. Identifies control and alarm panels
5. Identifies main delivery line and emergency shut-off valve
BANK AND RESERVE SYSTEMS

6. Identifies gas cylinders and contents
7. Identifies connecting piping
8. Identifies main line pressure alarm
9. Identifies manometers for each side of the bank
10. Identifies main supply line
11. Identifies main supply manometer and reads the service pressure
12. Identifies the manual or automatic switch-over mechanism
13. Switches service from one side to the other
14. Disconnects cylinders to be replaced
15. Connects full cylinders to the pipe connectors
16. Opens valves on all cylinders and checks for leaks
17. Ensures that adequate service pressure is maintained
2679_Ch09_123-144.indd 139 07/02/13 4:43 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
to modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch09_123-144.indd 140 07/02/13 4:43 PM


STUDENT: DATE:
GAS PRESSURE AND FLOW REGULATION

PERFORMANCE LEVEL
PERFORMANCE RATING
Evaluator: Setting:
Performance Level:
NA = Not applicable
Performance Rating:
1. Identifies and verifies contents of cylinder by label and color

2. Identifies and interprets marking on cylinder
3. Identifies the safety systems on large and small cylinders, wall outlets, regulators, and flowmeters
4. Selects the proper regulator and flowmeter for large and small cylinders and wall outlets
5. Observes proper handling, transportation, and storage of cylinder
6. Demonstrates proper “cracking” of cylinder; alerts any bystanders
7. Verifies presence of Gasloc® (O-ring, washer, gasket) seal on E cylinder
8. Properly connects regulator to cylinder
A. Detects and corrects any leaks
9. Properly opens cylinder valve for gas delivery
A. Reads cylinder pressure correctly
10. Identifies type of flowmeter and determines if it is compensated or noncompensated
11. Connects flowmeter correctly to wall outlet
A. Detects and corrects any leaks
12. Adjusts liter flow
13. Occludes outlet of flowmeter and explains observations
FOLLOW-UP
14. Determines length of duration of cylinder
15. Closes cylinder valve and bleeds pressure from regulator
16. Removes regulator from cylinder
17. Stores cylinder properly
18. Discusses hazards associated with cylinder
19. Discusses hazards associated with regulator
2679_Ch09_123-144.indd 141 07/02/13 4:43 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch09_123-144.indd 142 07/02/13 4:43 PM


STUDENT: DATE:
OXYGEN BLENDER
PERFORMANCE LEVEL
PERFORMANCE RATING
Evaluator: Setting:
Performance Level:
NA = Not applicable
Performance Rating:

2. Selects appropriate blender and gas sources
3. Attaches high-pressure hoses to appropriate gas source
4. Adjusts blender to the appropriate FIO2
5. Attaches the prescribed oxygen delivery device
6. Analyzes the set FIO2 to ensure blender accuracy
FOLLOW-UP
2679_Ch09_123-144.indd 143 07/02/13 4:43 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch09_123-144.indd 144 07/02/13 4:43 PM

CHAPTER Oxygen Analysis
INTRODUCTION Determining the accuracy of the delivered FIO2 is an important part of oxygen
administration. The only way to verify the concentration being delivered is by oxygen
analysis. The concentration of oxygen can be measured by three different physical
principles (physical/paramagnetic, electrical, and electrochemical). Most commonly used
are oxygen analyzers that work by the electrochemical principle (the polarographic and
galvanic fuel cell analyzers) or those electrical analyzers that operate on the principle of
thermal conductivity.1
OBJECTIVES 1. Given a specific oxygen analyzer, identify its component parts.

Upon completion of this 2. Calibrate an oxygen analyzer on room air and 100% oxygen.
3. Given an oxygen delivery system, analyze the Fio2.
4. Describe the effects of moisture buildup and pressure on the measured Fio2.
KEY TERMS
accuracy gain polarograph
calibration galvanic polarographic
diffusion paramagnetic sensor
efficacy permeability
145
2679_Ch10_145-152.indd 145 07/02/13 4:44 PM

Exercises
F Oxygen analyzers F Large-bore corrugated tubing
F In-line adaptors F Large-volume jet nebulizer
F Fuel cell cap F Sterile water
F Oxygen gas source—H or E cylinders F Plastic bag
F Large wrench F Small screwdriver
F Cylinder stands F Scissors
F Regulator with flowmeter F Spare batteries (see manufacturer’s
F Oxygen nipple adaptors specifications)
F Oxygen connection tubing
EXERCISE 10.1 OXYGEN ANALYZER COMPONENTS
1. Examine the device and identify the brand and type of analyzer you are using. Record the
information on your laboratory report. Identify the components. Depending on the style of
analyzer and its manufacturer, the component parts may vary. Refer to the individual
operating manual for specifics.
EXERCISE 10.2 CALIBRATION OF OXYGEN ANALYZERS
Regular calibration of 1. Obtain the analyzer.

oxygen analyzers is required 2. Set up the oxygen source by attaching a regulator with a Thorpe tube flowmeter to an
to ensure the accuracy of H cylinder.
measured FIO2. All oxygen 3. Attach an oxygen nipple adaptor to the DISS connection of the flowmeter outlet.
delivery systems should be 4. Secure the oxygen connecting tubing to the oxygen nipple adaptor.
checked at least once daily. 5. Check that the analyzer is in good operating condition. Make sure that the analog scale/
More frequent checks by LED, sensor cable, and electrode or fuel cell are intact.
calibrated analyzers may be 6. Prepare analyzer for use.
necessary in specific types of 7. Attach the sensor cable to the analyzer. Some types of fuel cell analyzers may also have on/
systems. You should use the off switches for the alarms and LED readings.
AARC clinical practice 8. With the sensor exposed to room air, adjust the calibration knob to read 21% oxygen.
guidelines (CPGs) for current 9. Place the sensor inside a plastic bag, as shown in Figure 10.1. Place the oxygen connecting
guidelines. The frequency of tubing inside the bag with the sensor. Turn on the flowmeter to 10 Lpm. (Flow needed may
analysis, whether continuous vary depending on the size of the bag used.) Loosely hold the bag closed.
or intermittent, determines 10. Allow the analyzer reading to stabilize. This may take 20 to 30 seconds depending on the
how often calibration is type of analyzer. Excessively long stabilization time or failure to reach greater than 80%
needed. oxygen may indicate that the sensor must be replaced.
11. While the sensor is exposed to 100% oxygen, adjust the calibration knob (gain) to
read 100%.
12. Shut off the oxygen. Remove the sensor from the bag. Relocate the analyzer to a different
part of the room and recheck at 21% calibration. Adjust if necessary.
13. After the calibration procedure is performed, the analyzer is now ready for use.
14. Turn off the analyzer when not in use.
2679_Ch10_145-152.indd 146 07/02/13 4:44 PM

C H A P T E R 10 | OX Y GEN ANALY S IS • 147
Figure 10.1. Calibration of an oxygen analyzer.
EXERCISE 10.3 OXYGEN ANALYSIS
For this exercise, assembly 1. Cut a single length of large-bore tubing (6 in.) from a roll, if it is not already available.
of the oxygen delivery 2. Place the analyzer sensor into an in-line adaptor. Make sure that it fits tightly.
system to be analyzed is 3. Attach a single length of large-bore tubing to one end of the in-line adaptor.
required. See Figure 10.2 4. Fill the nebulizer with sterile water. Adjust the nebulizer to an Fio2 of 0.40. Turn the
for the placement of the flowmeter on to 10 Lpm.
analyzer in line in a setup of 5. Attach the in-line adaptor with sensor to the ends of the aerosol tubing as close to the
a large-volume jet nebulizer. delivery device (mask or T-piece) as possible, as shown in Figure 10.2.
6. Position the sensor so that moisture cannot collect on the surface of the membrane. The
sensor should be facing down, as shown in Figure 10.3. Make sure the sensor and adaptor
are secured tightly in the circuit.
7. Allow the reading to stabilize. Record the results on your laboratory report.
8. If a disposable nebulizer is used, the Fio2 setting may not be accurate. If the reading on the
analyzer does not match the set Fio2, adjust the nebulizer setting to the prescribed Fio2.
Note any necessary adjustment. Record the actual nebulizer setting on your laboratory
report.
9. Repeat the procedure for an Fio2 of 0.60. Record the results on your laboratory report.
10. Turn off the analyzer when not in use.
Figure 10.2. Oxygen analysis.
2679_Ch10_145-152.indd 147 07/02/13 4:44 PM

Figure 10.3. In-line placement of analyzer sensor. (Courtesy

of Mine Safety Appliances, Pittsburgh, PA.)
R E FE R E N C E S
1. Cairo, JM, Pilbeam, SP: Mosby’s Respiratory Care Equipment, ed. 8. St. Louis, Mosby, 2009, p. 261.
2679_Ch10_145-152.indd 148 07/02/13 4:44 PM

Laboratory Report
CHAPTER 10: OXYGEN ANALYSIS
Name: Date:
Data Collection
EXERCISE 10.1 Oxygen Analyzer Components
Brand and type of analyzer: _____________________________________________________________________________________
List component parts: __________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
EXERCISE 10.3 Oxygen Analysis
1. Analysis of 0.40 _____________________________________________________________________________________________
Initial reading: ______________________________________________________________________________________________
Adjusted nebulizer setting: ____________________________________________________________________________________
2. Analysis of 0.60 _____________________________________________________________________________________________
Initial reading: ______________________________________________________________________________________________
Adjusted nebulizer setting: ____________________________________________________________________________________

1. Which type of analyzing method directly measures the concentration of oxygen? Which method directly measures
partial pressure?
2. How would decreased barometric pressure or increased altitude affect the reading of an oxygen analyzer? Why?
2679_Ch10_145-152.indd 149 07/02/13 4:44 PM

3. How would moisture or condensation buildup on the sensor membrane affect the measured Fio2? What measures can
be taken to prevent this?
4. A patient receiving mechanical ventilation has a polarographic oxygen analyzer in line with the ventilator circuit. Each
time the ventilator gives a positive pressure breath, you note the Fio2 increases and then returns to the ordered Fio2.
What is the cause of this problem and what actions should be taken?
5. Explain why routine oxygen analysis is important in:
A. Monitoring a newborn on supplemental oxygen.
B. Using an oxygen system that comprises compressed air and oxygen bleed-in.
C. Monitoring a home care patient using an oxygen concentrator.
6. A galvanic fuel cell analyzer is being used to monitor an oxygen setup for a pediatric patient. Upon calibration to room
air, the respiratory care practitioner notes that the analyzer is reading 17% when exposed to room air. What should
then be done?
2679_Ch10_145-152.indd 150 07/02/13 4:44 PM


STUDENT: DATE:
OXYGEN ANALYSIS
PERFORMANCE LEVEL
PERFORMANCE RATING
Evaluator: Setting:
Performance Level:
NA = Not applicable
Performance Rating:

2. Identifies the type of oxygen analyzers: electrochemical, polarographic, and galvanic

4. Assembles oxygen delivery device to be analyzed
5. Assembles additional oxygen flowmeter and attaches nipple adaptor
6. Secures oxygen connecting tubing to the adaptor
7. With the sensor exposed to room air, calibrates analyzer to room air and adjusts display if needed
8. Places sensor in 100% oxygen source gas (in bag, loosely held closed) and calibrates analyzer; adjusts reading if needed
9. Analyzes desired oxygen source; allows analyzer reading to stabilize
10. Adjusts FIO2 if necessary
FOLLOW-UP
11. Adjusts high and low FIO2 alarms for continuous monitoring
12. Caps sensor; unplugs analyzer when not in use
2679_Ch10_145-152.indd 151 07/02/13 4:44 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
to modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch10_145-152.indd 152 07/02/13 4:44 PM

CHAPTER Oxygen Therapy
Administration
INTRODUCTION Oxygen is one of the most commonly administered respiratory drugs. Although
administration of oxygen requires relatively simple skills, it is often misused or abused.
There is a variety of devices that can be used to deliver oxygen. The respiratory care
practitioner (RCP) must have a complete knowledge and understanding of the uses and
limitations of these devices, as well as the indications and hazards of oxygen therapy.
The primary goal of oxygen therapy is to reduce morbidity and mortality associated with
hypoxia. Proper administration, using the correct device, and assessing the adequacy of
the delivered FIO2 can have a significant positive impact on patient outcomes. Recently
designed high-flow cannula and mask devices have helped make FIO2 delivery more
efficient without having to resort to more invasive methods.
OBJECTIVES 1. Identify and assemble various oxygen delivery devices, such as the nasal cannula, high-flow
Upon completion of this nasal cannula, transtracheal catheter, simple mask, partial rebreathing mask, nonrebreathing
chapter, you will be able to: mask, high-flow nonrebreathing mask, and air entrainment (Venturi) masks.
2. Classify each oxygen delivery device as high flow or low flow.
3. Estimate the Fio2 for an oxygen delivery device, given the operating flow rate.
4. Given a patient scenario, select and administer the indicated oxygen device.
5. Demonstrate effective communication skills needed for patient–practitioner interaction.
6. Calculate inspiratory flow demands and total flows delivered for a given Fio2, using
air-to-oxygen mixing ratios.
7. Assess a patient for response to oxygen therapy.
8. Identify and correct common problems associated with oxygen delivery devices.
KEY TERMS
adverse flip-flop hypoxia mortality
anatomic dead space hypercapnea indication phenomenon
anoxia hypercarbia insufflation refractory
compensatory hyperventilation jet Venturi
dysrhythmia hypoventilation mechanical dead space
entrainment hypoxemia morbidity
153
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Exercises
F Alcohol swabs F Oxygen nipple adaptors
F Cylinder stands F Partial rebreathing masks
F Gloves F Plastic bags
F High-flow nasal cannula and humidifier F Prefilled bubble humidifiers
system F Pulse oximeter with probes
F High-flow nonrebreathing mask F Simple masks
F In-line adaptor F Sterile water
F Nasal cannulas F Transtracheal catheter
F Nonrebreathing masks F Vane respirometer
F “No Smoking” signs F Venturi masks, various brands and styles
F One-way valves F Watch with a second hand
F Oxygen analyzer F Wrenches
F Oxygen connection tubing
F Oxygen gas source: H, E cylinders with regu-
lators or piped in wall
EXERCISE 11.1 OXYGEN DEVICE IDENTIFICATION
Examine each of the following devices, identify all component parts, and record the correspond-
ing letters (if shown) on your laboratory report.
EXERCISE 1 1.1.1 N AS AL C AN N ULA ( FI G . 11.1)

Elastic strap or lariat ear tubes
Oxygen connecting tube
Nasal prongs
B A
Figure 11.1. Identification of nasal cannula

components.
2679_Ch11_153-172.indd 154 07/02/13 4:44 PM

C H A P T E R 11 | O X Y G E N T H E R A P Y ADM INIS TR ATION • 155
EXER C ISE 11 .1 .2 HIGH-F LO W N A S A L C A N N U LA ( FI G . 11.2)

Wide-bore nasal prongs
Elastic strap or lariat ear tubes
Specialized nondisposable humidifier
Oxygen connecting tube
Figure 11.2. High-flow nasal cannula. (Courtesy of Salter Labs,

Arvin, CA.)
EXER C ISE 11 .1 .3 S IMP LE MA S K ( FI G . 11.3)

Transparent plastic mask
Oxygen inlet
Exhalation ports
Malleable metal nosepiece
D A
Figure 11.3. Identification of simple mask components.
2679_Ch11_153-172.indd 155 07/02/13 4:44 PM

EXERCISE 1 1 .1 .4 PARTIAL REBREAT H I N G MA S K ( FI G . 11.4)

Gas inlet
Exhalation ports D
Malleable metal nosepiece
Reservoir bag B
Figure 11.4. Identification of partial rebreathing mask

components.
EXERCISE 1 1 .1 .5 N ON REBREATHIN G MA S K ( FI G . 11.5)

Nonrebreathing one-way valve C
Reservoir bag
Exhalation ports and valve
Gas inlet
D A
Figure 11.5. Identification of nonrebreathing mask components.
2679_Ch11_153-172.indd 156 07/02/13 4:44 PM

EXER C ISE 11 .1 .6 HIGH-F LO W N O N R E B R E AT H I N G MA S K

Obtain a high-flow nonrebreathing mask (if available), compare to the nonrebreathing mask (See
Fig. 11.5), note and record the differences on your lab report.
EXER C ISE 11 .1 .7 AIR EN TR A I N ME N T ( V E N T U R I ) MA S K ( FI G . 11.6)

Air entrainment port
Venturi tube
Oxygen inlet
Jet D
Exhalation valve
B
C B
C
Figure 11.6. Identification of air entrainment

mask components. A A
EXERCISE 11.2 OXYGEN THERAPY ADMINISTRATION

EXER C ISE 11 .2 .1 N ASAL C A N N U LA
Nasal cannulas deliver a 1. Verify “physician’s” order or protocol.
varying FIO2. Refer to 2. Obtain the following equipment:
Table 11.1 for the Nasal cannula
approximate FIO2 that H cylinder or piped-in oxygen gas source
can be delivered using this Regulator and/or flowmeter
oxygen administration Bubble humidifier
method. Oxygen nipple adaptor
“No Smoking” signs
3. Wash or sanitize your hands and apply PPE as appropriate.
Table 11.1. Approximate FIO2

O2 Flow Approximate FIO2
for Nasal Cannula (NC)
1 Lpm 0.24
2 Lpm 0.28
3 Lpm 0.32
4 Lpm 0.36
5 Lpm 0.40
6 Lpm 0.44
High-flow NC at 15 Lpm 1.0
2679_Ch11_153-172.indd 157 07/02/13 4:44 PM

4. With your laboratory partner acting as your patient, or using a human patient simulator,
perform the following:
A. Introduce yourself, verify your “patient’s identification,” explain the procedure, and
confirm that the “patient” understands.
B. Assess your “patient” before beginning oxygen therapy by measuring pulse, respiratory
rate, quality of respirations, color, and Spo2. Interview the “patient” to determine
whether dyspnea is present. Record the results on your laboratory report.
C. Explain safety considerations regarding smoking and electrical devices to your “patient.”
Verify that the “patient” understands.
D. Post “No Smoking” signs.
5. Set up the equipment as shown in Figure 11.7:
A. Attach the regulator to the oxygen cylinder.
B. Attach the bubble humidifier to the DISS outlet of the flowmeter.
NOTE: A humidifier may not be necessary with flow rates less than 4 Lpm. According to the
AARC clinical practice guidelines, a humidifier should be used with a nasal cannula when flow
rates of 4 Lpm or higher are necessary. Policy may vary at your clinical sites.
C. While aseptically keeping the nasal cannula in its wrapper, attach the oxygen connecting
tubing from the nasal cannula to the outlet of the humidifier.
D. Adjust the flowmeter to the prescribed level. Record the liter flow on your laboratory
report.
E. Pinch the oxygen connecting tubing to obstruct flow to verify function of the humidifier.
If the humidifier fails to make a whistling sound, check all connections for leaks.
F. Place the cannula in the “patient’s” nose and adjust the straps for fit. For a lariat-style
cannula, place the ear loops behind the “patient’s” ears and adjust the fit. Verify
“patient” comfort.
G. Reassess the “patient” after 5 minutes.
6. Repeat the exercise with a high-flow nasal cannula and special nondisposable humidifier.
A. Record pulse, respiratory rate, and SpO2 before and after application of the device.
Figure 11.7. Nasal cannula equipment assembly.
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EXER C ISE 11 .2 .2 TRAN S T R A C H E A L C AT H E T E R S

Transtracheal catheters 1. Verify the “physician’s” order or protocol.
deliver oxygen directly into 2. Obtain the following equipment:
the trachea, which allows Transtracheal catheter with chain necklace
for the use of lower flows H cylinder or piped-in oxygen gas source
of oxygen (i.e., 0.25 to Regulator or flowmeter
2 Lpm) to achieve a desired Oxygen nipple adaptor
level of oxygenation. Minor “No Smoking” signs
surgery is required to place a 3. Wash or sanitize your hands and apply PPE as appropriate.
stent that is later removed 4. With your laboratory partner acting as your patient, perform the following:
and replaced by a catheter A. Introduce yourself, verify your “patient’s” identification, explain the procedure, and
inserted into the trachea verify that the “patient” understands.
and secured by a special B. Assess your “patient” before beginning oxygen therapy by measuring pulse, respiratory
chain necklace. Standard rate, quality of respirations, color, and Spo2. Interview the “patient” to determine
tubing is then connected whether dyspnea is present.
to the catheter and oxygen 5. Set up the equipment as shown in Figure 11.8:
source. A humidification A. Attach the regulator to the oxygen cylinder.
device is not necessary.
NOTE: The transtracheal catheter is placed under sterile conditions in the operating room. It is
Complications can be
inserted directly into the trachea between the second and third tracheal rings. Since most labora-
prevented by providing
tory mannequins are not fitted for this device, placing the catheter on the “patient” may not be
patient education and
possible in the laboratory setting.
professional follow-up
care. B. The catheter is attached to standard oxygen connecting tubing and connected directly to
the flowmeter, which provides the oxygen source flow.
C. Adjust the flowmeter to the prescribed level. Humidification is not needed with this
device because the flow is below 4 Lpm.
NOTE: The transtracheal catheter uses 40% to 60% less oxygen flow to achieve adequate
oxygenation.
Figure 11.8. Transtracheal catheter equipment assembly.
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EXERCISE 1 1 .2 .3 S IMP LE MAS K

Simple oxygen masks Table 11.2. Approximate FIO2
Mask Liter Flow Approximate FIO2
also deliver a varying FIO2. for Oxygen Mask Devices
Refer to Table 11.2 for the Simple 6–10 Lpm 35–50%
approximate FIO2 that can Partial rebreathing Enough to keep bag Up to 70%
be delivered using the inflated (8–12 Lpm)
simple mask as well as by Nonrebreathing Enough to keep bag Up to 100%
partial rebreathing and inflated (8–12 Lpm)
nonrebreathing masks.
1. Verify the “physician’s” order or protocol.

2. Obtain the following equipment:
Simple mask
H cylinder or piped-in oxygen gas source
Regulator or flowmeter
Bubble humidifier
Oxygen nipple adaptor
4. With your laboratory partner acting as your patient, perform the following:
A. Introduce yourself, verify your “patient’s” identification, explain the procedure, and
verify that the “patient” understands.
rate, quality of respirations, color, and Spo2. Interview the “patient” to determine
whether dyspnea is present.
C. While aseptically keeping the simple mask in its wrapper, attach the oxygen connecting
tubing from the mask to the outlet of the humidifier. Attach the other end to the mask
oxygen inlet connector.
D. Adjust the flowmeter to the prescribed level.
NOTE: All masks should be used with a minimum flow rate of 5 Lpm.1
E. Pinch the oxygen connecting tubing to obstruct flow to verify function of the humidifier.
If the humidifier fails to make a whistling sound, check all connections for leaks.
F. Place the mask over the “patient’s” nose and mouth. Adjust the straps and nose bridge
for fit. Verify “patient” comfort.
G. Reassess the “patient” after 5 minutes.
Figure 11.9. Simple mask equipment

assembly.
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EXER C ISE 11 .2 .4 PARTIA L R E B R E AT H I N G O R N O N R E B R E AT H I N G MA S K

Refer to Table 11.2 for the 1. Verify the “physician’s” order or protocol.
approximate FIO2 delivered by 2. Obtain the following equipment:
partial rebreathing and Partial rebreathing or nonrebreathing mask
nonrebreathing masks. H cylinder or piped-in oxygen gas source
Bubble humidifier
3. Wash or sanitize your hands and apply PPE.
4. With your laboratory partner acting as your patient, or using a human patient simulator,
perform the following:
rate, quality of respirations, and color. A pulse oximeter may also be used to assess
oxygenation and vital signs. Interview the “patient” to determine whether dyspnea is
present.
NOTE: Most disposable bubble humidifiers will not allow for flow rates to be set above 6 Lpm.
Therefore, most institutions do not place disposable bubble humidifiers on partial or nonrebreath-
ing masks due to the higher flow these masks require. Valves may also stick closed due to mois-
ture accumulation. It is recommended that you follow your institution’s policy on the use of bub-
ble humidification with these masks.
C. While aseptically keeping the mask in its wrapper, attach the oxygen connecting tubing
from the mask to the outlet of the humidifier. Attach the other end to the mask oxygen
inlet connector.
D. Adjust the flowmeter to between 8 and 12 Lpm.
E. If using a bubble humidifier, pinch the oxygen connecting tubing to obstruct flow to
verify humidifier function. If the humidifier fails to make a whistling sound, check all
connections for leaks.
F. Place the mask over the “patient’s” nose and mouth. Adjust the straps and nose bridge
G. Readjust flow to ensure that the bag remains inflated during peak inspiration. Record
the liter flow on your laboratory report.
H. Reassess the “patient” after 5 minutes.
6. Repeat the exercise with a high-flow nonrebreathing mask.
A. Record pulse, respiratory rate, and Spo2 before and after application of the device.
Figure 11.10. Partial or nonrebreathing

mask equipment assembly.
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EXERCISE 11.3 AIR ENTRAINMENT (VENTURI) MASK
The FIO2 delivered by these Table 11.3. Air:Oxygen

Air:Oxygen Ratio FIO2
devices depends on the air Entrainment Mixing Ratios
entrainment ratios shown in 25:1 24%
Table 11.3. 10:1 28%
8:1 30%
7:1 32%
5:1 35%
3:1 40%
2:1 45%
1.7:1 50%
1:1 60%
0.6:1 70%
EXERCISE 1 1 .3 .1 ADMIN ISTR ATION O F O X Y G E N V I A A I R E N T R A I N ME N T D E V I C E

1. Verify the “physician’s” order or protocol.
2. Obtain the following equipment:
Air entrainment (Venturi) mask, jet, or entrainment port adaptors
H cylinder or piped-in oxygen gas source
4. With your laboratory partner acting as your patient, perform the following:
rate, quality of respirations, and color. A pulse oximeter may be used. Interview the
“patient” to determine whether dyspnea is present.
5. Set up the equipment as shown in Figure 11.11.
B. Attach the oxygen nipple to the DISS outlet of the flowmeter.
NOTE: Do not use a bubble humidifier with this device.
C. While aseptically keeping the mask in its wrapper, attach the oxygen connecting tubing
from the mask to the oxygen nipple. Attach the other end to the mask oxygen inlet
connector.
D. Adjust the flowmeter to the recommended liter flow for the Fio2 being used.
E. Place the mask over the “patient’s” nose and mouth. Adjust the straps and nose bridge
F. Reassess the “patient” after 5 minutes.
Figure 11.11. Air entrainment mask

equipment assembly.
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EXER C ISE 11 .3 .2 ACCUR A C Y O F F I O 2 W I T H A I R E N T R A I N ME N T D E V I C E S

1. Set the Venturi device on 40% and adjust the oxygen flow to the manufacturer’s
recommended setting. Record the device’s manufacturer, brand, and recommended setting
2. Calibrate and set up an oxygen analyzer.
3. While the oxygen is on, remove the mask from the Venturi device. Attach an oxygen sensor
to an in-line adaptor and connect the Venturi device to the adaptor. A single length of large-
bore corrugated tubing may be required to make this connection.
4. Measure the Fio2, allowing time for the reading to stabilize. Record the liter flow used and
the FIO2 measured on your laboratory report.
5. Decrease the oxygen flow rate to any liter flow of your choice below the manufacturer’s
recommended setting. Measure the Fio2, allowing time for the reading to stabilize. Record
the results on your laboratory report.
6. Increase the oxygen flow rate to any liter flow of your choice above the manufacturer’s
recommended setting. Measure the Fio2, allowing time for the reading to stabilize. Record
7. Adjust the Venturi device to another Fio2 of your choice.
8. Repeat steps 4, 5, and 6 for this new Fio2. Record the results on your laboratory report.
9. Place the Venturi device in a plastic bag. Insert an oxygen analyzer sensor into the bag.
Measure the Fio2 and record the results on your laboratory report.
10. Place the Venturi mask on a mannequin or human patient simulator. Cover the air
entrainments ports with a sheet or blanket pulled up to the “patient’s” chin. Analyze the
Fio2 by placing an oxygen sensor with an in-line adapter between the mask and Venturi
device. Record the FIO2 on your laboratory report.
EXER C ISE 11 .3 .3 ADEQUA C Y O F FLO W R AT E S FR O M A N A I R E N T R A I N MEN T D E V I C E

1. Measure your laboratory partner’s minute ventilation. Record the results on your laboratory
report.
2. Calculate your partner’s estimated inspiratory flow demand. Record the results on your
laboratory report. Show your work.
NOTE: The inspiratory flow demands can be estimated as three times the minute ventilation (VE).
3. With the Venturi device set at 40%, calculate the total flow being delivered from the mask
using the following formula:
Total flow = (Sum of air:oxygen entrainment ratios) × Flow rate
4. Based on your calculations, adjust the flow rate to meet your laboratory partner’s inspiratory
flow demand. Record this flow on your laboratory report.
EXERCISE 11.4 TROUBLESHOOTING

EXER C ISE 11 .4 .1 TROUBLE S H O O T I N G C O MMO N P R O B LE MS
1. The instructor or your laboratory partner will set up one or more of the following suggested
problems related to oxygen delivery devices. You are to inspect the equipment, identify the
problem, and correct it.
A. Incorrect equipment setup
B. Incorrect liter flow used for device
C. Loose humidifier cap
D. Kinked oxygen connecting tubing
E. Tubing disconnection
2. Record the problem and corrective action on your laboratory report.
2679_Ch11_153-172.indd 163 07/02/13 4:44 PM

EXERCISE 1 1 .4 .2 TROUBLES HOOTING D I A G R A MS

Figures 11.12 and 11.13 illustrate one or more problems with the setup of the oxygen delivery
systems. Identify the problem(s) and the corrective action to be taken. Record these on your labo-
ratory report.
Figure 11.12. Troubleshooting

oxygen device no. 1.
Figure 11.13. Troubleshooting

oxygen device no. 2.
RE F E RE N CE
1. Wilkins, R: Egan’s Fundamentals of Respiratory Care, ed. 9. Mosby, St. Louis, 2010, p. 879.
2679_Ch11_153-172.indd 164 07/02/13 4:44 PM

Laboratory Report
CHAPTER 11: OXYGEN THERAPY ADMINISTRATION
Name: Date:
Data Collection
EXERCISE 11.1 Oxygen Device Identification
E X E R C IS E 11 . 1. 1 N A S A L C A N NUL A
A. ______________________________________________________
B. ______________________________________________________
C. ______________________________________________________
E X E R C IS E 11 . 1. 2 H IG H -F L O W N ASAL CAN N UL A
A. ______________________________________________________
B. ______________________________________________________
C. ______________________________________________________
D. ______________________________________________________
E X E R C IS E 11 . 1. 3 S IMP L E M A S K
A. ______________________________________________________
B. ______________________________________________________
C. ______________________________________________________
D. ______________________________________________________
E X E R C IS E 11 . 1. 4 PA R T IA L R E BREATHIN G MASK
A. ______________________________________________________
B. ______________________________________________________
C. ______________________________________________________
D. ______________________________________________________
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E XE RCI SE 1 1 .1 . 5 N O NR E B R E AT H ING MA S K
A. ______________________________________________________
B. ______________________________________________________
C. ______________________________________________________
D. ______________________________________________________
E XE RCI SE 1 1 .1 . 6 H IG H -F L O W N O NR E B R E AT HIN G MASK
Observations:_________________________________________________________________________________________________
____________________________________________________________________________________________________________
E XE RCI SE 1 1 .1 . 7 A IR E NT R A INME NT (V E N T URI) MASK
A. ______________________________________________________
B. ______________________________________________________
C. ______________________________________________________
D. ______________________________________________________
E. ______________________________________________________
EXERCISE 11.2 Oxygen Therapy Administration
E XE RCI SE 1 1 .2. 1 N A S A L C A N NU L A S
Nasal Cannula
Before Oxygen Administration After Oxygen Administration
Pulse:
Respiratory rate (f) :
SpO2:
Prescribed liter flow:
Estimated FIO2:
High-Flow Nasal Cannula
Pulse:
SpO2:
Estimated FIO2:
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E X E R C IS E 11 . 2. 3 S IMP L E M A S K

Pulse:
SpO2:
Estimated FIO2:
E X E R C IS E 11 . 2. 4 PA R T IA L R E BREATHIN G AN D N ON REBREATHIN G MASKS
Partial Rebreather
Pulse:
SpO2:
Estimated FIO2:
Nonrebreather
Pulse:
SpO2:
Estimated FIO2:
High-Flow Nonrebreather
Pulse:
SpO2:
Estimated FIO2:
EXERCISE 11.3 Air Entrainment (Venturi) Mask
E X E R C IS E 11 . 3. 2 A C C U R A C Y OF F I O 2 W ITH AIR EN TRAIN MEN T DEVICES
Manufacturer and brand of Venturi device: _________________________________________________________________________
Recommended liter flow: ___________________________________
FIO2 set: 40%
Liter flow: _______________________________________________ Measured FIO2: ________________________________________
Decreased liter flow to: ____________________________________ Measured FIO2: ________________________________________
Increased liter flow to: _____________________________________ Measured FIO2: ________________________________________
2679_Ch11_153-172.indd 167 07/02/13 4:44 PM

FIO2 set:__________________________________________________
Liter flow: _______________________________________________ Measured FIO2: ________________________________________
Decreased liter flow to: ____________________________________ Measured FIO2: ________________________________________
Increased liter flow to: _____________________________________ Measured FIO2: ________________________________________
Measured FIO2 of Venturi device in bag: _______________________________
Explain why this result was obtained: _______________________________________________________________________________
_____________________________________________________________________________________________________________
Measured FIO2 of Venturi device covered with sheet: ____________________
Explain why this result was obtained: _______________________________________________________________________________
_____________________________________________________________________________________________________________
E XE RCI SE 1 1 .3 . 3 A D E Q U A C Y O F F L O W R AT E S F ROM AN AIR EN TRAIN MEN T DEVICE
Measured minute ventilation (VE): ___________________________________
Estimated inspiratory flow demand: __________________________________
Total flow delivered at 40%: ________________________________________
What adjustment to the liter flow, if any, would you have to make to meet your partner’s flow demand? ___________________________
_____________________________________________________________________________________________________________
EXERCISE 11.4 Troubleshooting
E XE RCI SE 1 1 .4 . 1 T R O U B LE S H O O T IN G C O M M ON PROBL EMS
1. Equipment used: ____________________________________________________________________________________________
Problem identified: __________________________________________________________________________________________
Corrective action: ___________________________________________________________________________________________
2. Equipment used: ____________________________________________________________________________________________
Problem identified: __________________________________________________________________________________________
Corrective action: ___________________________________________________________________________________________
E XE RCI SE 1 1 .4 . 2 T R O U B LE S H O O T IN G D IA G R AMS
Figure 11.11
Identify problem: _______________________________________________________________________________________________
Corrective action: ______________________________________________________________________________________________
Figure 11.12
Identify problem: _______________________________________________________________________________________________
Corrective action: ______________________________________________________________________________________________
2679_Ch11_153-172.indd 168 07/02/13 4:44 PM


Scenario: Mrs. Plaskowitz is a 60-year-old woman with COPD who is admitted to the emergency department (ED) via ambu-
lance wearing a nonrebreathing mask at 10 Lpm. Mrs. Plaskowitz, who was awake and alert when the ambulance arrived at
her home, is now extremely lethargic and somnolent. The ED physician orders you to change the oxygen delivery device to a
nasal cannula.
1. Briefly explain the cause of the “patient’s” lethargy.
2. If the “patient” were to remain on the nonrebreathing mask for at least 24 hours, what complications or hazards could
result from (a) the delivery method, and (b) the resulting oxygen concentration?
3. What liter flow would you recommend to the physician for the nasal cannula?
4. The pulmonary physician, who has been called in on this case, requests that you change the delivery device to a
Venturi mask at a comparable Fio2.
A. What Fio2 should be used?
B. The “patient” is noted to have a minute ventilation of 15 Lpm. What is the minimum liter flow, at this Fio2,
required to meet the “patient’s” inspiratory flow demand? Show your work.
5. Why is a minimum flow rate of 5 Lpm recommended for oxygen delivery by mask?
6. Why will an air entrainment mask never deliver 100% oxygen?
2679_Ch11_153-172.indd 169 07/02/13 4:44 PM

7. Briefly explain why the transtracheal catheter requires less oxygen flow than the nasal cannula to achieve a given arte-
rial partial pressure of oxygen.
8. Explain the difference between a high-flow and a low-flow oxygen delivery system. Give an example of each.
9. You observe a patient wearing a nonrebreathing mask and note that the bag completely deflates with each inspiration.
What actions, if any, should be taken?
10. What oxygen delivery device would you recommend for a patient who has just been successfully resuscitated and is
spontaneously breathing?
11. List at least three factors that will affect the Fio2 delivered by a low-flow oxygen system.
12. Complete the following table by calculating or providing the missing parameters. Show your work.
FIO2 O2 Flow Rate Entrainment Ratio Total Flow

14 Lpm 24 Lpm
0.28 8 Lpm
0.40 40 Lpm
5:1 36 Lpm
3 Lpm 7:1
0.45 5 Lpm
0.50 14 Lpm
0.32 5 Lpm
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STUDENT: DATE:
OXYGEN THERAPY
PERFORMANCE LEVEL
PERFORMANCE RATING
Performance Level:
NA = Not applicable
Performance Rating:

2. Educate patient on oxygen therapy.

4. Assesses vital signs, respirations, and SpO2
5. Attaches oxygen delivery device to nipple adaptor or humidifier if flow rate is greater than or equal to 4 Lpm
6. Adjusts the flowmeter to prescribed or appropriate liter flow
7. Verifies oxygen flow or concentration
8. Places the administration device properly and comfortably on the patient’s face
9. Confirms fit and verifies patient comfort
10. Assesses adequacy of the therapy
11. Makes any necessary flow rate adjustments
FOLLOW-UP
2679_Ch11_153-172.indd 171 07/02/13 4:44 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Evaluator (print name): Evaluator signature: Date:
Student Comments:
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CHAPTER Humidity Devices
INTRODUCTION The major functions of the upper airway are to warm, filter, and humidify the air that is
breathed. Many conditions, such as the presence of an artificial airway, dehydration,
fever, and the breathing of anhydrous gases, alter the efficiency of the upper airway in
performing these functions. The respiratory care practitioner (RCP), in these
circumstances, may deliver adjunctive humidity therapy to patients to minimize mucosal
drying and irritation and to prevent secretions from becoming inspissated. The safe
operation and use of these devices require an understanding of their capabilities as well
as their limitations.
OBJECTIVES 1. Identify the components of the heat and moisture exchanger (HME) and bubble, cascade, and
Upon completion of this wick humidifiers.
chapter, you will be able to: 2. Differentiate among the types of humidifiers, including their clinical uses, advantages, and
disadvantages.
3. Assemble and operate the various types of humidifiers.
4. Perform monitoring, maintenance, and troubleshooting techniques.
5. Determine, according to AARC clinical practice guidelines, the proper amount of
humidification for patients with artificial airways.
KEY TERMS
adhesion colloid hygroscopic environment
anhydrous crystalloid hypertonic osmosis
anion dehydration hypotonic relative humidity
calorie epithelium inspissate solute
cation hydration isotonic solution
cold stress hygrometer neutral thermal solvent
173
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Exercises
F Beaker or graduated cylinder F Lung simulator (optional)
F Bubble humidifier F Manual resuscitator with mask
F Clean towels F Regulator with flowmeter
F Compressed gas source F Scissors
F Continuous fill system F Sterile water bags or bottles
F Corrugated tubing F Temperature probe with adaptor
F Heat and moisture exchangers, various types F Wick humidifier
and brands
EXERCISE 12.1 BUBBLE HUMIDIFIER

EXERCISE 1 2.1.1 IDEN TIFIC ATION O F C O MP O N E N T S
Identify the components of a bubble humidifier, as shown in Figure 12.1, and record the follow-
ing on your laboratory report:
DISS connection
Outlet
Capillary inlet tube
Pop-off valve
Bubble diffuser
EXERCISE 1 2.1.2 SETUP OF A BUBB LE H U MI D I FI E R

1. If you are using a dry humidifier (not prefilled), fill the humidifier to the fill line with sterile
water.
2. Connect the bubble humidifier to the DISS outlet of a flowmeter.
3. Adjust the flow rate to 5 Lpm.
4. Record your observations on your laboratory report.
5. Shut the flowmeter off.
6. Remove the plastic protector from the outlet of the humidifier.
7. Readjust the flowmeter to 5 Lpm.
8. Obstruct the outlet of the humidifier.
10. Loosen the cap from the bottle.
D
C
Figure 12.1. Identification of bubble humidifier components.
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C H A P T E R 12 | HUM IDITY DEV IC ES • 175
12. Tighten the cap. Attach a small-bore oxygen connecting tube to the humidifier outlet.
13. Kink the tubing by bending it in half.
15. Turn the flowmeter to flush.
EXERCISE 12.2 HEAT AND MOISTURE EXCHANGER (HME)
Examine a heat and moisture exchanger. Compare HMEs from several manufacturers, as shown
in Figure 12.2. Perform the following:
1. Read the manufacturer’s insert. Record the brand used, expected H2O content, and resistance
specifications on your laboratory report.
2. Ventilate through the HME with a handheld resuscitator. Alternatively, connect the HME to
a lung simulator and attempt to bag through the HME. Record your observations on your
laboratory report.
3. Fill the HME with water. Let it stand for 5 minutes, then drain the excess water.
4. Ventilate through the HME with a handheld resuscitator. Alternatively, connect the HME to
a lung simulator and attempt to bag through the HME.
A B C
D E F
Figure 12.2. Heat and moisture exchangers. (Courtesy of Cardinal Health, Dublin, OH.)
2679_Ch12_173-186.indd 175 07/02/13 4:44 PM

EXERCISE 12.3 WICK HUMIDIFIER

EXERCISE 12.3.1 COMPON EN TS OF A W I C K H U MI D I FI E R
Identify the components of a wick humidifier (such as ConchaTherm® or Fisher & Paykel), as
shown in Figure 12.3, and record them on your laboratory report.
Inlet
Outlet
Heating element
Wick element
On/off switch
Temperature probe
Continuous feed port and line
EXERCISE 1 2.3.2 AS S EMBLY OF A WI C K H U MI D I FI E R A N D C O N T I N U O U S FE E D S Y S TE M

For this exercise, a 1. Note the temperature in the room prior to the start of the exercise and record it on your
compressor or high-flow laboratory report.
gas generator may be 2. Connect 12 6-inch lengths of corrugated tubing, cut in half with a T-drainage bag at the
used. most dependent loop, to the outlet of the humidifier.
3. Connect the flowmeter to a compressed gas source (air or oxygen). Attach an adaptor that
will connect the small-bore outlet of the flowmeter to large-bore corrugated tubing.
4. Attach three to six lengths of corrugated tubing from the flowmeter adaptor to the inlet of
the humidifier.
5. Assemble the unit with a continuous feed system, as shown in Figure 12.4, and attach the
water bag or bottle.
6. Open the clamp to the feed system, if applicable, and allow it to fill the humidifier to the fill
line. If a continuous feed is not available, aseptically fill the humidifier with sterile water.
7. Ensure that the heating unit is plugged in.
8. Attach a temperature probe at the end of the tubing, using a monitoring adaptor.
9. Turn the flow to 15 Lpm and adjust the temperature setting to 37°C.
10. Place your hand by the end of the corrugated tubing and record your observations on your
laboratory report.
11. Time how long it takes for the unit to reach 37°C.
C D
Figure 12.3. Components of a wick humidifier. (Courtesy

of Fisher & Paykel Healthcare, Auckland, New Zealand.)
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12. Once it has reached 37°C, wait another 15 minutes. Note the water level in the humidifier;
drain the condensate away from the unit and measure.
13. Record the original room temperature, the time to reach set temperature, the highest
temperature reached, the amount of condensate measured, and the ending water level on
Figure 12.4. Setup of a continuous

feed system. (Courtesy of Cardinal
Health, Dublin, OH.) B
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2679_Ch12_173-186.indd 178 07/02/13 4:44 PM
Laboratory Report
CHAPTER 12: HUMIDITY DEVICES
Name: Date:
Data Collection
EXERCISE 12.1 Bubble Humidifier
E X E R C IS E 12 . 1. 1 ID E NT IFIC ATION OF COMPON EN TS
A. _________________________________________________________________________________________________________
B. _________________________________________________________________________________________________________
C. _________________________________________________________________________________________________________
D. _________________________________________________________________________________________________________
E. _________________________________________________________________________________________________________
E X E R C IS E 12 . 1. 2 S E T U P O F A BUBBL E HUMIDIF IER
OBSERVATIONS
Plastic protector on, flow rate to 5 Lpm: _____________________________________________________________________________
_____________________________________________________________________________________________________________
Obstruct the outlet of the humidifier, flow rate to 5 Lpm: ________________________________________________________________
_____________________________________________________________________________________________________________
Loosen the cap from the bottle: ___________________________________________________________________________________
_____________________________________________________________________________________________________________
Kinked tubing: _________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Flowmeter to flush: _____________________________________________________________________________________________
_____________________________________________________________________________________________________________
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EXERCISE 12.2 Heat and Moisture Exchanger (HME)
Brand used: ___________________________________________________________________________________________________
Expected H2O content: ___________________________________________________________________________________________
Resistance specifications: _______________________________________________________________________________________
_____________________________________________________________________________________________________________
Ventilate through dry HME: _______________________________________________________________________________________
Resistance recorded on simulator: _________________________________________________________________________________
HME wet: ____________________________________________________________________________________________________
Resistance recorded on simulator: _________________________________________________________________________________
EXERCISE 12.3 Wick Humidifier
E XE RCI SE 1 2 .3 . 1 C O MP O N E N T S O F A W IC K HUMIDIF IER
Brand used: __________________________________________________________________________________________________
Components identified:
A. ___________________________________________________________________________________________________________
B. ___________________________________________________________________________________________________________
C. ___________________________________________________________________________________________________________
D. ___________________________________________________________________________________________________________
E. ___________________________________________________________________________________________________________
F. ___________________________________________________________________________________________________________
G. ___________________________________________________________________________________________________________
E XE RCI SE 1 2 .3 . 2 A S S E M B LY O F A W IC K H U MIDIF IER AN D CON TIN UOUS F EED SYSTEM
Room temperature: ________________________________________ Hand at end of tube—Observations: _______________________
Time to reach temperature: _________________________________ Highest temperature: __________________________________
Amount of condensate: _____________________________________ Ending water level: ____________________________________
Observations: _________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
2679_Ch12_173-186.indd 180 07/02/13 4:44 PM


1. What are the limitations of an HME? What are the advantages? What effect does moisture have on HME function?
2. Which humidifiers are the most efficient? What effect does temperature have on the efficiency of the unit?
3. What are the minimum standards for humidity devices, according to the American National Standards Institute
(ANSI)?
4. What are the advantages and disadvantage of using a continuous feed system to fill a humidifier?
5. Define humidity. What is the purpose of using humidifiers in the clinical setting? What complications can result if inad-
equate humidification is provided?
6. What are the recommended liter flows when using a bubble humidifier?
2679_Ch12_173-186.indd 181 07/02/13 4:44 PM

7. For each of the following scenarios, identify what type of humidifier you would use. Explain your rationale.
A. Nasal cannula at 3 Lpm
B. Nasal cannula at 6 Lpm
C. Postoperative patient on short-term mechanical ventilation
D. Long-term mechanically ventilated patient with inspissated secretions
8. List five hazards or complications of humidification devices.
2679_Ch12_173-186.indd 182 07/02/13 4:44 PM


STUDENT: DATE:
HUMIDIFICATION THERAPY
PERFORMANCE LEVEL
PERFORMANCE RATING
Performance Level:
NA = Not applicable
Performance Rating:


3. Identifies the following types of humidifiers: bubble, wick, jet, HME
4. Bubble humidifier: Uses when oxygen flow is 4 Lpm or higher with nasal cannula
5. For HME: Assures no contraindications are present to its use according to AARC CPG
A. Places in circuit at proper location
6. Wick humidifier: Obtains and sets up continuous feed system for sterile water and water traps
7. Assembles servo heating system and verifies function, then sets temperature between 32°C to 37°C as appropriate
A. Jet nebulizer (aerosol generator): Obtains pre-filled nebulizer and aerosol drainage bags
8. Adjusts liter flow to ensure patient inspiratory demands being met (minimum VE × 3)
A. For wick: Uses high-flow flowmeter if needed
B. For jet nebulizer: If FIO2 60% or higher, sets up tandem nebulizer or GIN nebulizer
9. Obtains and calibrates oxygen analyzer
10. Analyzes FIO2 delivered and adjusts device if needed
11. Applies device to the patient
12. Verifies gas temperature after appropriate time period
FOLLOW-UP
14. Replaces HME if visibly soiled or resistance to breathing has significantly increased
15. Replaces prefilled sterile water reservoir on bubble humidifier and jet nebulizer as needed
16. Replaces sterile water bag on continuous feed system as needed
17. Empties drainage reservoir or water traps as needed
2679_Ch12_173-186.indd 183 07/02/13 4:44 PM


PERFORMANCE RATING:
5 Independent: Near flawless performance; minimal errors; able to perform without supervision; seeks out new learning; shows initiative;

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

F PASS: Satisfactory Performance
F FAIL: Unsatisfactory Performance (check all that apply)
SIGNATURES
Student Comments:
2679_Ch12_173-186.indd 184 07/02/13 4:44 PM


STUDENT: DATE:
HUMIDIFICATION WITH ARTIFICIAL AIRWAY
PERFORMANCE LEVEL
PERFORMANCE RATING
Performance Level:
NA = Not applicable
Performance Rating:


3. Identifies the proper heated humidifier to be used with an artificial airway
4. Obtains and sets up continuous feed system for sterile water and water traps
5. Assembles servo heating system and verifies function, then sets temperature between 32°C to 37°C as appropriate
6. Adjusts liter flow to ensure patient inspiratory demand
7. Obtains and calibrates oxygen analyzer
8. Analyzes FIO2 delivered and adjusts device if needed
9. Selects and applies trach collar or T-piece to the artificial airway
10. Applies device to the patient
11. Verifies gas temperature after appropriate time period
FOLLOW-UP
13. Replaces sterile water bag on continuous feed system as needed
14. Empties drainage reservoir or water traps as needed
2679_Ch12_173-186.indd 185 07/02/13 4:44 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch12_173-186.indd 186 07/02/13 4:44 PM

CHAPTER Aerosol
Generators
INTRODUCTION An aerosol is defined as a suspension of solid or liquid particles in a gas. Aerosols may
be administered to deliver medication or to deliver a bland solution for the purpose of
sputum induction, treatment of upper airway edema, or humidification of a bypassed or
compromised upper airway.1
The respiratory care practitioner (RCP) has many devices available to generate aerosols
for application to the upper or lower airway. These devices include small-volume
nebulizers (SVNs), large-volume nebulizers (LVNs), gas injection nebulizers (GINs), nasal
atomizers, metered-dose inhalers (MDIs) and auxiliary spacing devices, dry powder
inhalers (DPIs), and ultrasonic nebulizers (USNs).
The selection and use of the most appropriate device is based on the specific clinical
application and the desired therapeutic goals. The RCP should consider several factors in
this selection, including the intended target area of the respiratory tract to be treated; the
proven efficacy of the technique being used; patient preference, coordination, and
cooperation; availability of medications; convenience; and patient tolerance.2 Before the
RCP can apply these devices in the clinical setting, the RCP must understand the
operating principles, advantages, and limitations of each device.
This chapter focuses on aerosol delivery devices used for continuous aerosol therapy.
Chapter 14 emphasizes medication delivery devices and techniques.
OBJECTIVES 1. Differentiate among the types of aerosol generators by operating principle.

Upon completion of this 2. Given a specific clinical situation, select and apply the appropriate aerosol delivery device.
3. Discuss the limitations of each type of aerosol delivery device.
4. List the hazards and complications associated with aerosol delivery.
5. Practice communication skills needed to explain the application of an aerosol device to a
patient and confirm patient understanding.
6. Practice medical charting for the therapeutic application of an aerosol delivery device.
7. Apply infection control guidelines and standards associated with aerosol delivery equipment
and procedures, according to OSHA regulations and CDC guidelines.
187
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KEY TERMS
aerosol couplant nebulizer tandem
amplitude deposition particulate titrate
atomizer expectoration penetration tonicity
baffle hypotonic piezoelectric
bland impaction pneumatic
Exercises
F Aerosol masks F Oxygen analyzer and in-line adaptor
F Briggs adaptors (T-pieces) F Oxygen nipple adaptors
F Compressed gas sources (oxygen and air) F Oxygen supply tubing
F Corrugated tubing F Scissors
F Face tents F Sterile water
F Flowmeters F Stethoscope
F Gas injection nebulizer (GIN) F Temperature probes and in-line adaptors
F Heating elements F Tracheostomy collars
F Intubated and tracheostomized airway man- F Ultrasonic nebulizer
agement trainer F Watch with second hand
F Large-volume nebulizers (LVNs) F Water traps or water drainage bags
F Normal saline vials (3 or 5 mL) F Y-connectors
EXERCISE 13.1 LARGE-VOLUME NEBULIZER (LVN)

EXERCISE 13.1.1 COMPON EN TS OF A N LV N
Examine a large-volume nebulizer and use the following list to identify the labeled components in
Figure 13.1. Record the components in your laboratory report.
DISS connection
Air entrainment ports
Fio2 adjustment (entrainment selector)
Jet
C
Baffle
Capillary tube
Pressure pop-off (not shown) D
Filter
Outlet
B
E
A
F
Figure 13.1. Components of a large-volume
nebulizer. (From Persing, G: Entry-level Respiratory
Care Review, ed. 2. WB Saunders, Philadelphia,
2679_Ch13_187-200.indd 188 08/02/13 4:51 PM

C H A P T E R 13 | A ER OS OL GENER ATOR S • 189
EXER C ISE 13 .1 .2 ASSEMB LY O F A N LV N

1. Assemble the nebulizer according to the manufacturer’s instructions.
2. Aseptically fill the nebulizer with sterile water. If a prefilled nebulizer is used, be sure not to
contaminate the internal surfaces.
3. Attach the heating element and adjust the settings, if available, to achieve 37°C.
4. Attach the nebulizer to the DISS outlet of a flowmeter.
5. Adjust the Fio2 by turning the entrainment selector to the 100% setting.
6. Turn the flow to 10 Lpm and observe the mist density and output, the total flow, and the
size of the entrainment port. Record your observations on your laboratory report.
7. Turn the flowmeter to 15 Lpm or as high as it will go. Record the highest flow achievable
8. Return the flow to 10 Lpm.
9. Set the entrainment selector to 35% oxygen. Note any changes in the mist density and
output, the total flow, and the size of the entrainment port. Record your observations on
10. Set the entrainment selector in between any two oxygen settings. Record the settings on
11. Attach six lengths of corrugated tubing.
12. Place the temperature probe adaptor one tubing length from the patient interface. Insert the
temperature probe.
13. Place another temperature probe adaptor about halfway between the nebulizer and the
patient interface. Insert the temperature probe.
14. Note the time. Record the beginning temperature on both probes on your laboratory
report.
15. Measure the time it takes for the temperature to reach 37°C on each probe. Record the
times and final temperatures on your laboratory report.
16. Analyze the Fio2 and record it on your laboratory report.
17. Adjust the Fio2 by turning the entrainment selector to 0.40. Analyze the Fio2 and readjust
the entrainment selector if necessary to ensure that the nebulizer is delivering 40% oxygen.
18. Put water in the corrugated tubing so that the lumen of the tube is occluded in the loop, or
“belly,” of the tubing, as shown in Figure 13.2.
19. Analyze the Fio2 and record it on your laboratory report.
20. Drain the water from the tubing by “milking” the tubing away from the device and into a
waste receptacle.
21. Attach a water trap by cutting the corrugated tubing in the belly of the tubing and
attaching the trap to the ends of the tubing, as shown in Figure 13.3.
22. Turn the liter flow to 5 Lpm. Observe the mist output and record your observations on
Figure 13.2. Water in the corrugated tubing.
2679_Ch13_187-200.indd 189 08/02/13 4:51 PM

Figure 13.3. Insertion of a water trap in

a nebulizer setup.
EXERCISE 13.2 AEROSOL DELIVERY DEVICES

EXERCISE 13.2.1 IDEN TIFIC ATION O F A E R O S O L D E LI V E R Y D E V I C E S
Using the following list, identify the labeled devices shown in Figure 13.4. Record the devices in
Tracheostomy collar (mask)
Aerosol mask
Face tent
Briggs adaptor (T-piece)
EXERCISE 1 3.2.2 AP P LIC ATION OF A N A E R O S O L G E N E R AT I N G D E V I C E

Using your laboratory partner 1. Check the “chart”:
as a patient, or a human Verify the physician’s order or protocol for mode of delivery and Fio2.
patient simulator or Check the patient’s diagnosis.
mannequin, set up and 2. Gather the necessary equipment:
deliver a heated aerosol Large-volume nebulizer, prefilled if available
at an FIO2 of 0.40 (unless Corrugated tubing
otherwise specified by your Sterile water
instructor) for each of the Heating element
following scenarios: a Temperature probe and in-line adaptor
spontaneously breathing Oxygen flowmeter and gas source
patient (Fig. 13.5); a Water trap or aerosol T-drainage bag
spontaneously breathing Scissors
patient with facial injuries Appropriate aerosol delivery device (mask, T-piece, tracheostomy collar, or face tent)
(Fig. 13.6); a tracheostomized 3. Wash or sanitize your hands. Apply standard precautions and transmission-based isolation
patient (Fig. 13.7); and an procedures as appropriate.
intubated patient (Fig. 13.8). 4. Introduce yourself and your department. Verify the “patient’s” identification. Explain the
procedure to the “patient” and confirm that the “patient” understands.
5. Assemble the equipment.
Figure 13.4. Aerosol delivery devices. A B C D
2679_Ch13_187-200.indd 190 08/02/13 4:51 PM

Figure 13.5. Aerosol setup with a face mask. Figure 13.6. Aerosol setup with a face tent.
Figure 13.7. Aerosol setup with a tracheostomy

collar.
Figure 13.8. Aerosol setup with a Briggs adaptor.
2679_Ch13_187-200.indd 191 08/02/13 4:51 PM

6. Adjust the gas source to the appropriate flow rate for adequate flow to meet the “patient’s”
inspiratory demand. In most cases, this is between 8 and 12 Lpm. For oxygen concentrations
of 60% or above, a tandem or double setup or gas injection system should be used. This is
demonstrated in Exercise 13.5. REMEMBER: Never place “dead” equipment on a patient!
7. Attach the delivery device to the “patient.” Ensure “patient” comfort.
8. Analyze the Fio2 and adjust the entrainment selector if necessary.
9. Document the procedure appropriately. “Chart” your therapy on your laboratory report.
EXERCISE 13.3 ULTRASONIC NEBULIZER (USN)

EXERCISE 13.3.1 L ARGE-V OL UME US N
Using the following list, identify the labeled components of the large-volume ultrasonic nebulizer
shown in Figure 13.9. Record them on your laboratory report.
On/off switch
Continuous feed inlet
Couplant chamber
Diaphragm
Medication chamber
Amplitude adjustor
Blower
Piezoelectric element
EXERCISE 1 3.3.2 AP P LIC ATION OF TH E LA R G E -V O LU ME U S N

1. Fill the couplant chamber with tap water.
2. Aseptically fill the medication chamber with 50 mL of sterile water.
F
H
C
Figure 13.9. Components of an ultrasonic nebulizer.
2679_Ch13_187-200.indd 192 08/02/13 4:51 PM

3. Plug the unit into an electrical outlet.
4. Turn the unit on with the amplitude at its lowest setting. Note the time and gradually turn
the amplitude to the maximum setting. Record your observations on your laboratory report.
5. Track the time required for the unit to go dry and record it on your laboratory report.
6. Refill the medication chamber.
7. Insert an in-line adaptor to titrate oxygen into the gas flow. Attach one end of a small-bore
oxygen tube to the adaptor and the other end to a flowmeter. Adjust the flow to obtain an
Fio2 of 0.30.
8. Drain the tap water from the couplant chamber. Fill it with sterile distilled water.
9. Reassemble the USN and turn it on. Record your observations of USN function on your
laboratory report.
EXER C ISE 13 .3 .3 MEDIC AT I O N S MA LL-V O LU ME U S N

1. Obtain a small-volume medication USN. Identify the brand and model, components, and
controls of your unit and record them on your laboratory report.
2. Insert a disposable diaphragm.
3. Add 1 mL of normal saline solution (NSS) to medication chamber.
4. Turn unit on and note mist density. Adjust if possible.
5. Continue to add NSS to maximum capacity. Note this amount on your laboratory report.
EXERCISE 13.4 GAS TITRATION
1. Assemble the gas titration system as shown in Figure 13.10 with the nebulizer attached to a
compressed gas source.
2. Turn the flow to 10 Lpm.
3. Adjust the oxygen flowmeter to achieve the following values of Fio2: 0.24, 0.30, and 0.45.
4. Record your observations and liter flows required on your laboratory report.
Figure 13.10. Setup for titrating to a specific FIO2.
2679_Ch13_187-200.indd 193 08/02/13 4:51 PM

EXERCISE 13.5 TANDEM NEBULIZER SETUP
1. Assemble two large-volume nebulizers in tandem, as shown in Figure 13.11.

2. Set the flowmeters on each device to 10 Lpm.
3. Turn the flow rate up to 15 Lpm. Record your observations on your laboratory report.
Return the flow to 10 Lpm.
4. Set the entrainment selector on each nebulizer to the following: 0.50, 0.60, and 0.80.
Observe the mist density and output and the total flow. Record your observations for each
setting on your laboratory report.
“Wye” adapter
Briggs
“T” Piece
Reservoir
tube
Figure 13.11. Tandem nebulizer setup.
R E FE R E N C E S
1. American Association for Respiratory Care: AARC clinical practice guideline: Bland aerosol administration:
2003 update. Respir Care 48(5):539–533, 2003.
2. American Association for Respiratory Care: AARC clinical practice guideline: Selection of an aerosol
delivery device. Respir Care 37:891–897, 1992.
2679_Ch13_187-200.indd 194 08/02/13 4:51 PM

Laboratory Report
CHAPTER 13: AEROSOL GENERATORS
Name: Date:
Data Collection
EXERCISE 13.1 Large-Volume Nebulizer
A. __________________________________________________________________________________________________________
B. __________________________________________________________________________________________________________
C. __________________________________________________________________________________________________________
D. __________________________________________________________________________________________________________
E. __________________________________________________________________________________________________________
F. __________________________________________________________________________________________________________
G. __________________________________________________________________________________________________________
E X E R C IS E 13 . 1. 2 A S S E M B LY OF AN LVN
Type and brand of nebulizer used: ________________________________________________________________________________
Entrainment Selector at 100%
Mist density at 100%: __________________________________________________________________________________________
Total flow at 100%: ____________________________________________________________________________________________
Entrainment port size: ______________________________ Flowmeter at 15 Lpm: _________________________________________
Entrainment Selector at 35%
Mist density at 35%: ___________________________________________________________________________________________
Total flow at 35%: _____________________________________________________________________________________________
Entrainment port size: __________________________________________________________________________________________
Temperature Probes
FIO2 set between _______________________________ and ____________________________ Time: ________________________
Heating element setting: ________________________________________________________________________________________
Initial temperature of probe nearest humidifier: ___________________ Nearest patient interface: ___________________________
Time to achieve 37°C of probe nearest humidifier: _________________ Nearest patient interface: ___________________________
Final temperature of probe nearest humidifier: ____________________ Nearest patient interface: ___________________________
Analysis of FIO2: ___________________________________________________________________________________________________________________________________________________
2679_Ch13_187-200.indd 195 08/02/13 4:51 PM

Water in Tubing
Analysis of FIO2: ______________________________________________________________________________________________
5 Lpm flow: __________________________________________________________________________________________________
EXERCISE 13.2 Aerosol Delivery Devices
E XE RCI SE 1 3 .2 . 1 ID E NT IFIC AT IO N O F A E R O S OL DEL IVERY DEVICES
A. __________________________________________________________________________________________________________
B. __________________________________________________________________________________________________________
C. __________________________________________________________________________________________________________
D. __________________________________________________________________________________________________________
E XE RCI SE 1 3 .2 . 2 A P P L IC AT IO N O F A N A E R OSOL GEN ERATIN G DEVICE
Chart the procedures for each of the following scenarios.
1. Spontaneously breathing patient: _____________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
2. Spontaneously breathing patient with facial injuries: ______________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
3. Tracheostomized patient: ___________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
4. Intubated patient: _________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
2679_Ch13_187-200.indd 196 08/02/13 4:51 PM

E X E R C IS E 13 . 3. 1 L A R G E -V O LUME USN
A. __________________________________________________________________________________________________________
B. __________________________________________________________________________________________________________
C. __________________________________________________________________________________________________________
D. __________________________________________________________________________________________________________
E. __________________________________________________________________________________________________________
F. __________________________________________________________________________________________________________
G. __________________________________________________________________________________________________________
H. __________________________________________________________________________________________________________
E X E R C IS E 13 . 3. 2 A P P L IC AT IO N OF THE L ARGE-VOL UME USN
Amplitude at maximum observations: _____________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Time until unit is dry: _____________________________ Liter flow to achieve FIO2 of 0.30: __________________________________
Drained couplant chamber observations: __________________________________________________________________________
____________________________________________________________________________________________________________
Couplant filled with sterile water observations: _____________________________________________________________________
____________________________________________________________________________________________________________
E X E R C IS E 13 . 3. 3 ME D IC AT IO N SMAL L -VOL UME USN
Brand and model used: ________________________________________________________________________________________
Components and controls: ______________________________________________________________________________________
____________________________________________________________________________________________________________
Amount of saline solution added: _________________________________________________________________________________
EXERCISE 13.4 Gas Titration
Observations: ________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Liter flow required to achieve FIO2 values of 0.24 _________________ 0.30 ____________________ 0.45 ______________________
2679_Ch13_187-200.indd 197 08/02/13 4:51 PM

EXERCISE 13.5 Tandem Nebulizer Setup
Observations of 15 Lpm flow rate: ________________________________________________________________________________
____________________________________________________________________________________________________________
Observations of mist density and total flow:
FIO2 = 0.50 ___________________________________________________________________________________________________
FIO2 = 0.60 ___________________________________________________________________________________________________
FIO2 = 0.80 ___________________________________________________________________________________________________

1. What was the effect on the Fio2 of water in the corrugated tubing? Why did that effect occur?
2. What effect did increasing the amplitude of the USN have on the aerosol’s density? What determines the particle size of
the USN?
3. The physician orders an ultrasonic treatment to be given to a patient who requires nasal oxygen at 5 Lpm. How would
you adapt the equipment?
4. Under what circumstances would it be necessary to use tandem nebulizers?
5. What are five factors that should be considered when choosing the proper aerosol delivery device for a patient?
2679_Ch13_187-200.indd 198 08/02/13 4:51 PM


STUDENT: DATE:
AEROSOL GENERATORS: LARGE-VOLUME NEBULIZERS (LVNs)
PERFORMANCE LEVEL
PERFORMANCE RATING
Performance Level:
NA = Not applicable
Performance Rating:

2. Selects appropriate aerosol generator and delivery device to achieve therapeutic objectives: LVN, tandem setup, gas injection
nebulizer (GIN)

4. Sets flow rate to appropriate level (8–12 Lpm or GIN recommendation) to achieve adequate mist and total flow
5. Determines patient total flow demand
A. Determines total flow being generated by device
B. Adjusts gas source and/or mist density to the appropriate flow rate for adequate flow to meet the patient’s inspiratory demand
C. For oxygen concentrations 60% or higher, uses a tandem or double nebulizer setup, or GIN
6. Attaches the delivery device to the patient and ensures patient comfort
7. Analyzes the FIO2 and adjusts the entrainment selector or mist density if applicable
8. Reassesses the patient after application of the aerosol device
9. Collects sputum, labels, and sends to lab if indicated
FOLLOW-UP
2679_Ch13_187-200.indd 199 08/02/13 4:51 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
to modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch13_187-200.indd 200 08/02/13 4:51 PM

CHAPTER Cardiopulmonary
Pharmacology
Review
INTRODUCTION A primary responsibility of the respiratory care practitioner (RCP) is the delivery of
pharmacological agents to the upper and lower airways. The respiratory tract is an ideal
route of administration for these agents because they are rapidly absorbed, reduced
dosages can be used, and the side effects are minimized. There is a variety of indications
for the use of these drugs, including bronchodilation, sputum induction, mobilization of
secretions, and delivery of anti-inflammatory, anti-infective, and surface-active agents. As
a result, there are many drugs that can be delivered. New drugs and delivery devices are
frequently being approved by the FDA and marketed. It is imperative that the RCP keep
up with the rapid changes in drugs and delivery methods. The RCP must have a complete
understanding of the classification, indications, contraindications, mechanism of action,
and modes of delivery. In addition, the RCP must also know the sequence of
administration, which drugs can or cannot be combined, and how to use any special
administration equipment. The RCP needs to be able to explain the use of new devices to
patients for home care use.
OBJECTIVES 1. State the dosage, action, and route and mode of delivery for the respiratory medications listed
Upon completion of this in objective 3.
chapter, you will be able to: 2. Identify any specialized delivery devices (e.g., DPI [dry powder inhaler]) and proprietary names
used.
3. Identify the generic names for each of the following medications:
A. Accolate
B. Advair
C. Aerobid
D. Alupent
E. Asmanex, Nasonex
F. Atrovent
G. Brovana
H. Coly-Mycin
I. Combivent
J. Cromolyn
K. Curosurf
L. DuoNeb
M. Flovent, Flonase
N. Foradil
O. Infasurf
P. Maxair Autohaler
Q. Mucomyst
R. NebuPent
S. Proventil, Ventolin
201
2679_Ch14_201-210.indd 201 07/02/13 4:44 PM

T. Pulmicort, Rhinocort
U. Pulmicort Respules
V. Pulmozyme
W. Serevent
X. Singulair
Y. Spiriva
Z. Symbicort
AA. TOBI
BB. Vanceril
CC. VapoNefrin, Micronefrin
DD. Xopenex
EE. Other as specified by instructor
4. Practice calculation of drug dosages.
KEY TERMS
adrenergic diuretic mucokinetic protein binding
affinity drugs mucolytic racemic
agonist dyskinesia muscarinic receptor
anaphylaxis enzyme nicotonic sedation
antagonist excretion osteoporosis solubility
anticholinergic hormone parasympatholytic subcutaneous
antihistamine hypersensitivity parasympathomimetic surfactant
antitussive hypoglycemia parenteral sympatholytic
atopic idiosyncrasy pharmaceutical sympathomimetic
β agonist inotropic pharmacodynamics tachyphylaxis
bronchoactive interaction pharmacognosy thrush
catecholamine ionization pharmacokinetics tolerance
cholinergic leukotriene pharmacology topical
chronotropic metabolism potency toxicology
decongestant metabolite potentiation
Exercises
F Drug package inserts or manufacturer’s F Internet drug database sites
information F Physicians’ Desk Reference (PDR)
F Internet access
2679_Ch14_201-210.indd 202 07/02/13 4:44 PM

C H A P T E R 14 | C A R D I O P U LM O N A RY P H A R M AC OLOGY R EV IEW • 203
EXERCISE 14.1 REVIEW OF RESPIRATORY MEDICATIONS

EXER C ISE 14 .1 .1 P HAR MA C O LO G I C A L T E R MI N O LO G Y
For the following definitions, provide the correct term and record the terms using the table pro-
vided on your laboratory report.
1. Hand-bulb device to produce large-particle spray

2. Absorbing moisture
3. Applied to skin or mucous membranes for systemic effect
4. Having attraction to
5. Usefulness
6. Bringing harm
7. Complex protein catalyst
8. Containing small blood vessels
9. Decreased response or sensitivity to subsequent repeated doses of the same substance or the
need for increasing doses to maintain a constant response
10. Device to initiate an action or process
11. Effects = algebraic sum
12. Prevention
13. Specialized area in a cell that recognizes and bonds with specific substances producing some
effect on the cell
14. Relief of pain
15. Route of administration other than the GI tract
16. Strength
17. Sudden tolerance
18. Injected into the skin
19. Applied to certain area (i.e., skin or mucous membrane) for localized effect
20. Washing out of organ or cavity
21. Study of natural drugs and their constituents, sources
22. Study of harmful effects of drugs in an organism
23. Study or phase of drugs including dosage, preparation, dispensation, and routes of
administration
24. Under the tongue
25. Injected under the skin
26. Sympathetic blood vessel receptors
27. Severe allergic reaction
28. Cough suppressant
29. Adrenergic receptors in heart
30. Natural or synthetic chemicals similar in structure to epinephrine
31. Produces effect of acetylcholine
32. Affecting time or rate
33. Increasing urination
34. Difficulty performing movement
35. Process of elimination as in waste matter or normal discharge
36. Coughing up and spitting out of sputum
37. Allergic asthma
38. Substance originating in an organ or gland and transported by bloodstream to other areas
where it has a regulatory effect
39. Abnormally increased susceptibility to a stimulus of any kind
40. Peculiar or individual reaction
41. Affecting the force of muscle contraction
42. Inflammatory mediator, product of arachidonic acid metabolism
43. Product of chemical reaction
44. Breaking down of mucus
45. Stimulation of parasympathetic neuroeffector sites, includes increased mucous and salivary
gland discharge, decreased heart rate, vasodilation, and hypotension
46. “Pins and needles”
47. Combination of left and right image stereoisomer
48. Collection receptacle for medication of nebulizer
49. Administration of a drug to allay irritability or excitement, calming effect
50. Auxiliary device for MDI (metered-dose inhaler)
51. Stimulating epinephrine receptors
52. Narrowing or spasm of blood vessels
2679_Ch14_201-210.indd 203 07/02/13 4:44 PM

EXERCISE 1 4 .1 .2 C LAS S IF ICATION , G E N E R I C N A ME S , A N D S U P P LY O F C O MMO N

R ESPIR ATOR Y MED I C AT I O N S
1. Using the PDR and other reference materials, complete Table 14.1 on your laboratory report.
Your instructor may add or delete from the medication list.
2. Use the following class abbreviations:
Sympathomimetic bronchodilator = SPM
Parasympatholytic bronchodilator = PSPM
Anti-infective = AI
Antiasthmatic mast cell stabilizer = AM
Antiasthmatic leukotriene modifier = AL
Mucolytic = ML
Steroid = ST
Surface active = SA
3. Answer the following questions on your laboratory report:
A. Which medication(s) contain(s) fluticasone?
B. DuoNeb and Combivent contain which two drugs?
C. What is the generic name of Proventil and Ventolin?
D. Which bronchodilator should not be a first-line drug for acute bronchospasm?
E. TOBI and Pulmozyme are commonly used to treat the respiratory complications
associated with what disease?
EXERCISE 14.2 CALCULATION OF DRUG DOSAGES
To calculate percent solutions and dosages, the following formula is most often used:
Original mg × Desired mL = Desired mg × Original mL

The components are cross-multiplied and solved for the missing value.
The most frequently used conversion factors required for pharmacology calculations are as
follows.
2.2 lb = 1 kg (body weight)
1,000 µg = 1 mg
1,000 mg = 1 g
1,000 mL = 1 L
5 mL = 1 tsp
1:00 solution = 1% = 10 mg/mL
Calculate the following dosages of commonly used respiratory care medications. Show your work
and answers on your laboratory report.
1. A physician orders a 2.5 mL/kg dose of Curosurf surfactant replacement therapy for a 4.4 lb
neonate. You are to administer it one half dosage at a time. How many milliliters would be
required for the initial application?
2. A standard dose of 0.3 mL of a 5% solution of metaproterenol is given. How many
milligrams are being administered?
3. A 2.5 mg dose of a 0.5% solution of albuterol sulfate is being administered four times daily
from a 20 mL multidose vial. How many patients could be treated in one day at this dose
from this vial?
4. An amount of 300 mg of pentamidine is mixed in 6 mL of sterile water. What is the percent
solution being administered? How much would need to be administered if a 60 mg dose was
ordered?
5. An amount of 5 mL of 20% Mucomyst is ordered. How many milligrams are being
administered?
6. Ipratropium bromide unit dose solution comes in a 0.02% solution. If the active ingredient is
500 µg, what is the equivalent amount of active ingredient in milliliters?
7. The unit dose Atrovent has been backordered. What drug could you recommend to the
physician to substitute for the Atrovent? If this drug came in a 0.4 mg/mL solution and the
physician ordered a 1 mg dose, how many milliliters would need to be drawn up to nebulize
this dose?
8. Dornase alfa has been ordered for a patient with cystic fibrosis. A single 2.5 mL ampule
contains a 2.5 mg dose. What is the percent solution of this medication?
2679_Ch14_201-210.indd 204 07/02/13 4:44 PM

Laboratory Report
CHAPTER 14: CARDIOPULMONARY PHARMACOLOGY REVIEW
Name: Date:
Data Collection
EXERCISE 14.1 Review of Respiratory Medications
E X E R C IS E 14 . 1. 1 P H A R MA C O L OGICAL TERMIN OL OGY
1. 14. 27. 40.
2. 15. 28. 41.
3. 16. 29. 42.
4. 17. 30. 43.
5. 18. 31. 44.
6. 19. 32. 45.
7. 20. 33. 46.
8. 21. 34. 47.
9. 22. 35. 48.
10. 23. 36. 49.
11. 24. 37. 50.
12. 25. 38. 51.
13. 26. 39. 52.
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E XE RCI SE 1 4 .1 . 2 C L A S S IF IC AT IO N, G E N E R IC N AMES, AN D SUPPLY OF COMMON RESPIRATORY MEDICATI ONS
Table 14.1 Respiratory

Medication Summary Brand Name Generic Name Class Forms Dose Hazards
Advair
Atrovent
Azmacort
Beclovent
Brovana
Curosurf
Flovent
Intal
Maxair
Mucomyst
Pentamidine
Pulmozyme
Serevent
Singulair
Spiriva
Symbicort
Tilade
TOBI
Ventolin
Xopenex
A . _________________________________________________________________________________________________________
B. _________________________________________________________________________________________________________
C. _________________________________________________________________________________________________________
D. _________________________________________________________________________________________________________
E. _________________________________________________________________________________________________________
2679_Ch14_201-210.indd 206 07/02/13 4:44 PM

EXERCISE 14.2 Calculation of Drug Dosages
1. __________________________________________________________________________________________________________
2. __________________________________________________________________________________________________________
3. __________________________________________________________________________________________________________
4. __________________________________________________________________________________________________________
5. __________________________________________________________________________________________________________
6. __________________________________________________________________________________________________________
7. Drug: _____________________________________________________________________________________________________
Dosage: ___________________________________________________________________________________________________
8. __________________________________________________________________________________________________________

1. List two hazards or complications of each of the following and explain how each could be assessed and prevented or
treated:
A. An aerosolized sympathomimetic
B. A parasympatholytic bronchodilator
C. A surfactant replacement agent
D. 3% hypertonic saline
E. An aerosolized anti-infective agent
2. A physician has written orders for a COPD patient to receive bronchodilator treatments. The medication orders are as
follows: 3 mg Combivent unit dose q4h with 18 mcg Spiriva DPI 1 puff daily. Briefly describe how you would handle
this situation and what further recommendations you would make?
2679_Ch14_201-210.indd 207 07/02/13 4:44 PM

3. When delivering nebulized Mucomyst, what medication can be added to the treatment to prevent bronchospasm?
4. Why has the use of chlorofluorocarbons as propellants in MDIs been discontinued?
5. An asthmatic patient is being given 0.5 mL nebulized albuterol treatment. The patient has a history of atrial fibrilla-
tion. During the treatment, the patient’s heart rate increases from 98 bpm to 132 bpm and the patient complains of ex-
treme shakiness. The treatment is suspended and the nurse is informed. What suggestion would you make for future
treatments?
2679_Ch14_201-210.indd 208 07/02/13 4:44 PM


STUDENT: DATE:
CALCULATION OF DRUG DOSAGES
PERFORMANCE LEVEL
PERFORMANCE RATING
Performance Level:
NA = Not applicable
Performance Rating:
1. Converts body weight in pounds to body weight in kilograms

2. Converts the amount of active drug from micrograms to milligrams
3. Calculates the amount of drug to be administered if given a drug strength in mg/kg
4. Calculates the amount of drug in milligrams to be administered given the percent solution and milliliters
5. Calculates the percent solution of a drug given the amount of drug in mg/mL
6. Calculates the amount of drug to be administered in milliliters given the drug in percent solution and micrograms
2679_Ch14_201-210.indd 209 07/02/13 4:44 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
to modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch14_201-210.indd 210 07/02/13 4:44 PM

CHAPTER Aerosol and
Medication
Therapy
INTRODUCTION As discussed in the previous chapter, there are many different types of bronchoactive
medications. These medications are delivered by different devices, such as dry powder
inhalers (DPIs), metered-dose inhalers (MDIs), small-volume nebulizers (SVNs), continuous
nebulizers, and ultrasonic nebulizing devices. Some medications such as pentamidine,
ribavirin, or surfactants may require specialized delivery devices. Techniques for delivery
of aerosol medications include short-term intermittent treatments and long-term or
continuous nebulization. With many new aerosol delivery devices entering the market,
the respiratory care practitioner (RCP) must be able to recommend and select the
appropriate delivery device for patients of all ages and capabilities. The device the RCP
chooses should allow for the most precise delivery with the least amount of waste.1 In
addition, the RCP must monitor and evaluate the therapeutic effectiveness and adverse
reactions, and appropriately document each procedure.
The RCP should always be cognizant of potential limitations to these procedures caused
by such factors as device design, use of accessory devices, use of artificial airways,
mechanical ventilation, condition or irritation of the airways, medication dosage,
inadequate instruction or technique, and patient compliance.
OBJECTIVES 1. Select and use various aerosol delivery devices and adjunctive equipment given specific clinical
Upon completion of this situations.
chapter, you will be able to: 2. Discuss the indications, advantages, disadvantages, limitations, contraindications, and hazards
of each type of aerosol delivery device and method used for medication delivery.
3. Perform patient assessment and monitor and evaluate patient response to aerosolized
medication administration.
4. Obtain a sputum specimen for analysis using sputum induction techniques.
5. Chart an aerosol medication treatment.
6. Practice communication skills needed for the administration of an aerosol medication
treatment.
used for aerosol medication delivery, according to OSHA regulations and CDC guidelines.
KEY TERMS
actuator dispersal agent holding chamber propellant
additive emesis induction spacer
auxiliary fasciculation interface
cumulation flaccid lavage
211
2679_Ch15_211-236.indd 211 07/02/13 4:44 PM

Exercises
F Aeroneb-Pro™ nebulizer F Oxygen nipple adaptors
F Aerosol masks F Peak flowmeters with disposable mouthpieces
F Auxiliary spacing devices (spacers or holding F Respirgard™ or ISO-NEB™ nebulizers
chambers) F Scissors
F Circulaire® nebulizer F Small-volume nebulizers, mouthpieces
F Compressed gas source, air or oxygen F Sputum specimen cup
F Continuous bronchodilator medication F Sterile water
nebulizers (HEART®, MiniHEART®, F Stethoscopes
UniHEART®, Flowmist™, or Hope™)
F 3% hypertonic saline solution (optional)
F Demonstration discus
F Tissues
F DPIs and demo units
F T-piece or Briggs adaptor
F In-line MDI adaptors for ventilator circuits
F Tracheostomy collars
F Intubated and trached airway training
F Ultrasonic nebulizer
mannequin
F Unit-dose normal saline solutions
F Large-bore aerosol tubing
F Unit-dose parasympatholytic bronchodilator
F MDIs, placebo and sample medications
F Unit-dose Pulmicort Respules®
F Multidose normal saline solution
F Unit-dose racemic epinephrine
F Multidose vials, Mucomyst (acetylcysteine)
F Unit-dose sympathomimetic bronchodilators,
F Multidose vials, sympathomimetic
variety
bronchodilators, variety
F Watch with second hand
F 2 mL and 5 mL syringes
F Oxygen connecting tubing
EXERCISE 15.1 SMALL-VOLUME NEBULIZERS

EXERCISE15.1.1 IDEN TIFIC ATION OF C O MP O N E N T PA R T S
Examine the small-volume nebulizer and identify the components shown in Figure 15.1.
Capillary tube
Baffle F G
Jet
Gas source inlet
Outlet
Reservoir tubing
Mouthpiece A
E
B
Figure 15.1. Components of a small-volume D C

nebulizer.
EXERCISE 1 5 .1 .2 OPER ATION OF A S MA LL-V O LU ME N E B U LI Z E R

1. Assemble a small-volume nebulizer, as shown in Figure 15.2.
2. Attach the connecting tubing of the nebulizer to the nipple adaptor of a flowmeter or
compressor outlet.
3. Aseptically instill 1 mL of normal saline into the medication cup. Do not allow the tip of the
saline vial to touch any inside surface of the nebulizer.
2679_Ch15_211-236.indd 212 07/02/13 4:44 PM

C H A P T E R 15 | A E R O S O L A N D M EDIC ATION THER AP Y • 213
Figure 15.2. Assembly of a small-volume nebulizer.
4. Turn the flow to 6 Lpm. Record your observations regarding mist density on your laboratory
report.
5. Now instill an additional 2 mL of saline into the medication cup. Record your observations
regarding mist density on your laboratory report.
6. Turn the flow to 10 Lpm. Record your observations on your laboratory report.
7. Turn the flow down to 2 Lpm. Record your observations regarding mist density on your
laboratory report.
8. Add an additional 3 mL to the nebulizer and turn the flow to 6 Lpm. Record your
observations regarding mist density on your laboratory report.
EXERCISE 15.2 IDENTIFICATION OF COMPONENT PARTS OF ADDITIONAL DELIVERY

DEVICES
EXER C ISE 15 .2 .1 DRY P O W D E R I N H A LE R ( D P I ) D E V I C E S A N D ME D I C AT I O N S
1. Examine the two dry powder inhalers in Figure 15.3.
Identify the medication associated with each DPI listed and record on your laboratory report.
2. Practice using each device. Practice explaining how to use the device to your “patient.”
3. Identify the specific medication associated with each of the DPI devices shown in Figure 15.3.
4. Identify the nonactive ingredients and dispersal agents for one of the medications and record
this information on your laboratory report.
Figure 15.3. Dry powder inhalers:

(A) Advair Diskus® and (B) Spiriva. A B
2679_Ch15_211-236.indd 213 07/02/13 4:44 PM

EXERCISE 1 5 .2 .2 METER ED-DOSE INH A LE R S ( MD I S ) A N D ME D I C AT I O N S

1. Examine a MDI and identify the component parts shown in Figure 15.4.
2. Examine the auxiliary spacing devices (spacers) shown in Figure 15.5.
3. Examine the in-line adaptors for MDI delivery to ventilated patients, as shown in
Figure 15.6.
4. Practice using the Maxair™ Autohaler™ MDI device (Fig. 15.7).
Aerosol can
Inhaled air entry
Drug suspension
Metering valve
Valve
stem
Figure 15.4. Components of a metered-dose inhaler.
(Adapted from Witek, TJ Jr and Schachter, EN: Atomizing
Pharmacology and Therapeutics in Respiratory Care. nozzle
WB Saunders, Philadelphia, 1994, p. 40, with
Actuator body Mouthpiece
permission.)
MDI canister
MDI canister
Actuator
Mouthpiece
Mouthpiece
cover
Extension
device
A B Reservoir
MDI canister
Locking MDI canister
tabs
End cap Main body MDI canister

Reservoir holder
Figure 15.5. Spacing devices. (Adapted from bag Strap
Mouthpiece
Rau, JL Jr: Respiratory Care Pharmacology,
ed. 4. Mosby-Year Book, St. Louis, 1994, p. 53, Flow
with permission.) C indicator D Mouthpiece
2679_Ch15_211-236.indd 214 07/02/13 4:44 PM

A B
Figure 15.6. In-line MDI adaptors. ([A] Courtesy of Monaghan Medical Corporation, Syracuse, NY. [B] Courtesy of Diemolding Corp., Diemolding
Healthcare Division, Canastota, NY. [D] Courtesy of Instrumentation Industries, Inc., Bethel Park, PA.)
Figure 15.7. Maxair™ Autohaler™ MDI. (Courtesy of Graceway

Pharmaceuticals, Exton, PA.)
2679_Ch15_211-236.indd 215 07/02/13 4:44 PM

EXERCISE 15.3 SPECIALTY NEBULIZERS
1. Examine filtered nebulizer systems such as the ISO-NEB™ or Respirgard™ nebulizers and
identify the component parts shown in Figure 15.8.
Mouthpiece
One-way valve
Medication reservoir
Nebulizer
Expiratory filter
Connecting tubing
2. Compare a filtered nebulizer system such as the Respirgard™ or ISO-NEB™ with a small-
volume nebulizer and a large-volume nebulizer. Record your comparisons on your laboratory
report.
3. Examine the HEART® nebulizer shown in Figure 15.9 and compare it to a small-volume
nebulizer.
4. Do the same for the Circulaire® nebulizer shown in Figure 15.10. Compare these devices
with a small-volume nebulizer and a large-volume nebulizer. Record your comparisons on
5. Repeat for Aeroneb Pro® (Fig. 15.11) system if available. Record your comparisons on your
laboratory report.
6. Repeat for PARI® nebulizer if available (Fig. 15.12). Record your comparisons on your
laboratory report.
7. Repeat for AeroEclipse® BAN nebulizer (Fig. 15.13) if available. Record your comparisons
A A
Intake C
D
F
Figure 15.8. Respirgard™ nebulizer. (Adapted

from Rau, JL Jr: Respiratory Care Pharmacology, E
ed. 4. Mosby-Year Book, St. Louis, 1994, p. 291,
with permission.)
Aerosol mask
IV
pump
Oxygen
blender IV drip tubing
UniHEART–IV
Flow- FIO2 nebulizer Plug
meter
Oxygen supply tubing

Figure 15.9. HEART® nebulizer and continuous nebulization setup. (Adapted from Westmed, Inc., Tucson, AZ. with permission.)
2679_Ch15_211-236.indd 216 07/02/13 4:44 PM

A C
B
Grip here
Rotation F D
of bowl
A – Mouthpiece E – Circulaire body
B – Variable resistor F – Nebulizer bowl/jet
G C – Aerosol reservoir bag G – Oxygen tubing
D – Nebulizer top H – Gas outlet
Figure 15.10. Circulaire® nebulizer. (Courtesy of

Westmed, Inc., Tucson, AZ.)
Figure 15.11. Aeroneb Pro® nebulizer. (Courtesy of

Cardinal Health, Dublin, OH.)
Figure 15.12. PARI LC® PLUS nebulizer. (PARI LC® PLUS

is a registered trademark of PARI GmbH.)
Figure 15.13. AeroEclipse® nebulizer. (Courtesy of

Monaghan Medical Corporation, Plattsburgh, NY.)
2679_Ch15_211-236.indd 217 07/02/13 4:44 PM

EXERCISE 15.4 AEROSOL MEDICATION ADMINISTRATION
NOTE: For the following There are many factors to consider when selecting an aerosol delivery device. Some are patient
exercises, placebo related, others are related to the drug selected. These factors are summarized in Table 15.1.
medications may be used.
However, for any student
with asthma or reactive Table 15.1 Factors Influencing the
General Considerations Disease state and severity
airway disease, an actual Selection of an Aerosol Delivery
Ease of use
bronchodilator may be Device
Power source
administered with a Cost
prescription if the student is Drug availability
agreeable. Contamination
Practitioner safety
Patient age and cooperation
SVN Patient unable to follow directions
Poor vital capacity (<1.0 L)
Unable to perform inspiratory hold maneuver
Tachypnea (>25 bpm)
Medication only available as a solution
MDI Oriented, cooperative, coordinated patient
Adequate vital capacity
Respiratory rate <25 breaths/min
Drug only available in MDI form
DPI Poor MDI coordination
Sensitivity to propellants (CFC)
Drug availability
Inspiratory flow >60 Lpm
EXERCISE 1 5 .4 .1 DRY P OWDER IN HA LE R ( D P I ) A D MI N I S T R AT I O N

1. Gather the necessary equipment for DPI administration of a sympathomimetic
bronchodilator, parasympatholytic bronchodilator, and steroid. Note which medications
and devices were used on your laboratory report.
2. Check the “chart” for medication order or protocol, diagnosis, history, and other pertinent
information.
3. Wash or sanitize your hands. Apply standard precautions and transmission-based isolation
4. Introduce yourself and your department to your “patient.” Verify “patient” identification.
Explain the purpose of the procedure and verify that your “patient” understands.
5. Explain which medications are being used and what they do.
6. Position the “patient” in an upright position.
7. Assess the “patient” before therapy for heart rate and pattern, respiratory rate and pattern,
auscultation, and peak flow measurement.
8. Instruct your “patient” on DPI administration as follows:
A. Demonstrate how to place the medication capsule or blister pack in the device, if
applicable.
B. Explain and demonstrate how to puncture the DPI capsule with the device.
C. Instruct the “patient” to hold the device upright and not to turn or tip the device.
D. Instruct the “patient” to inhale quickly (flow >60 Lpm), maintain breath hold for 5 to
10 seconds, and exhale normally.
E. Instruct the “patient” to dispose of the DPI capsule by holding the open device over a
waste bin.
NOTE: Instruct the “patient” not to touch the punctured capsule when disposing of DPI cap-
sule. This will protect the patient from accidentally handling the punctured capsule and inad-
vertently touching their eyes. With medications, such as Spiriva, the eyes must be protected
from drug exposure.
9. Administer the DPI in the appropriate sequence.
10. Reassess the “patient” when finished.
2679_Ch15_211-236.indd 218 07/02/13 4:44 PM

11. Have the “patient” rinse mouth and gargle after administration of the steroid.
12. Reinstruct if necessary.
13. Dispose of the DPI capsule by holding the open device over the waste bin.
14. Chart your therapy on your laboratory report.
EXER C ISE 15 .4 .2 METER E D -D O S E I N H A LE R ( MD I ) A D MI N I S T R AT I O N

1. Gather the necessary equipment for MDI administration: MDI, spacer, peak flowmeter,
disposable mouthpiece, stethoscope, and watch with second hand.
2. Note the type of propellant and nonactive ingredients contained in the MDI medication and
record on your laboratory report.
3. Check the “chart” for medication order or protocol, diagnosis, history, and other pertinent
information.
4. Wash or sanitize your hands. Apply standard precautions and transmission-based isolation
5. Introduce yourself and your department to your “patient.” Verify “patient” identification.
Explain the purpose of the procedure and verify that your “patient” understands.
6. Position the “patient” in an upright position.
7. Assess the “patient” before therapy for heart rate and pattern, respiratory rate and pattern,
8. Instruct your “patient” on MDI administration as follows:
A. Remove the dust cap and inspect the actuator mouthpiece for any foreign objects.
B. Shake the MDI. Actuate one puff into the air while holding the canister upside down if
more than 24 hours have elapsed since the last use.
C. Place the spacer onto the end of the actuator adaptor.
D. Place the spacer mouthpiece into the mouth. Keep the tongue relaxed and the teeth out
of the way of the opening. Exhale normally, not to residual volume (RV).
E. Begin a slow inspiration through the mouth and activate the MDI as inhalation
continues.
F. Inhale maximally. Maintain inspiratory hold for 5 to 10 seconds if possible.
G. Wait at least 1 to 2 minutes between puffs.
H. Recap the mouthpiece.
9. If an inhaled corticosteroid is being used, have the “patient” rinse mouth and gargle throat
with water when finished.
10. Reassess your “patient’s” pulse, respiratory rate, breath sounds, and peak flow.
11. Instruct the “patient” to rinse the mouthpiece and spacer with warm water at least daily,
and disinfect the mouthpiece assembly in a mixed solution of one-half white vinegar and
one-half water for 20 to 30 minutes once a week. Rinse thoroughly and air dry.
12. Instruct the “patient” on how to determine the MDI contents remaining:
A. There are 200 puffs per MDI.
B. Float canister in water. A full canister will sink, an empty canister will float.
C. Use a commercial dose counter (Fig. 15.14).
13. Chart the therapy on your laboratory report.
Figure 15.14. Dose counter.
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EXERCISE 1 5 .4 .3 S MALL -VOLUME N E B U LI Z E R ( S V N ) A D MI N I S T R AT I O N

NOTE: For the following 1. Gather the necessary equipment to deliver a medication via small-volume nebulizer by
exercises, normal saline mouthpiece: small-volume nebulizer, connecting tubing, nipple adaptor, compressed gas
may be used. However, for source (air or oxygen), mouthpiece, one 6-inch length of large-bore corrugated aerosol
any student with asthma tubing, unit-dose normal saline, unit-dose or multidose vial of an aerosolized
or reactive airway disease, bronchodilator, sputum specimen cup, watch with second hand, stethoscope, and peak
an actual bronchodilator flowmeter.
may be administered with 2. Check the “chart” for order or protocol, diagnosis, history, and other pertinent
a prescription if the student information.
is agreeable. 3. Wash or sanitize your hands and apply standard precautions and transmission-based
isolation procedures as applicable.
4. Assemble the SVN.
5. Introduce yourself and your department. Verify “patient” identification, explain the
procedure, and verify that your “patient” understands.
6. Position the “patient” in an upright seated position, if possible.
7. Perform pretreatment assessment of heart rate and pattern, respiratory rate and pattern,
8. Aseptically fill the nebulizer with the ordered medication and diluent.
9. Set the compressed gas source to 6 to 8 Lpm.
10. Place the mouthpiece in the “patient’s” mouth and instruct the “patient” to take slow, deep
breaths with occasional inspiratory hold as tolerated.
11. Periodically reassess pulse throughout the treatment.
12. Modify the “patient’s” technique as needed based on response, and reinstruct as necessary.
13. Terminate the treatment when the complete medication dosage is nebulized or significant
adverse reactions occur.
14. Reassess vital signs, breath sounds, and peak flow.
15. Encourage the “patient” to cough and expectorate sputum. Observe for volume, color,
consistency, odor, and presence or absence of blood.
16. Rinse the nebulizer with sterile water and air dry. Place it aseptically in a patient
treatment bag.
NOTE: The nebulizer should not be rinsed with tap water because of the possible contamination
with Legionella.2
18. Notify appropriate personnel of any adverse reactions or other concerns.
EXERCISE 1 5 .4 .4 AER OSOL DEL IVER Y B Y MA S K

Repeat Exercise 15.4.3 using an aerosol mask in place of the mouthpiece for administration, as
shown in Figure 15.15.
Figure 15.15. Aerosol delivery by mask.
2679_Ch15_211-236.indd 220 07/02/13 4:44 PM

EXER C ISE 15 .4 .5 AER OSO L D E LI V E R Y B Y T R A C H E O S T O MY C O LLA R

Repeat Exercise 15.4.3 using a tracheostomy collar, as shown in Figure 15.16.
Figure 15.16. Aerosol delivery by tracheostomy collar.
EXER C ISE 15 .4 .6 AER OSO L D E LI V E R Y B Y T-P I E C E O R B R I G G S A D A P T O R

Repeat Exercise 15.4.3 using a T-piece or Briggs adaptor, as shown in Figure 15.17.
Figure 15.17. Aerosol delivery by Briggs

adaptor.
2679_Ch15_211-236.indd 221 07/02/13 4:44 PM

EXERCISE 15.5 FILTERED NEBULIZERS
1. Obtain a filtered nebulizer system such as Respirgard™ or ISO-NEB™ nebulizers and

assemble the component parts.
2. Aseptically instill 3 mL of normal saline into the medication cup.
3. Turn the flow to 6 Lpm. Record your observations of the density, particle size, and release of
particles into the atmosphere on your laboratory report.
4. Turn the flow to 10 Lpm. Record your observations of the density, particle size, and release
of particles into the atmosphere on your laboratory report.
EXERCISE 15.6 SPUTUM INDUCTION
NOTE: For best results in 1. Gather the necessary equipment for sputum induction via ultrasonic nebulizer: ultrasonic
inducing sputum, a 3% nebulizer, electrical outlet, aerosol mask, several lengths of large-bore corrugated aerosol
hypertonic saline solution is tubing, bottle of sterile water or saline, watch with second hand, and stethoscope.
used. However, because of 2. Check the “chart” for order or protocol, diagnosis, history, and other pertinent
its irritating nature and the information.
possibility of adverse 3. Wash or sanitize your hands and apply standard precautions and transmission-based
reactions, your instructor isolation procedures as applicable.
may use sterile water or 4. Introduce yourself and your department. Verify “patient” identification, explain the
saline for this exercise. procedure, and verify that your “patient” understands.
Caution should always be 5. Position the “patient” in an upright seated position, if possible.
taken with any student who 6. Perform pretreatment assessment by measuring heart rate and pattern, respiratory rate and
has asthma or reactive pattern, and auscultation.
airway disease. 7. Assemble the ultrasonic nebulizer. Fill the couplant chamber with tap water. Plug the unit
into an electrical outlet.
8. Attach the large-bore corrugated tubing to the nebulizer outlet and attach the aerosol mask
to the end of the tubing.
9. Aseptically fill the medication chamber of the nebulizer with the ordered medication.
10. Turn the unit on and adjust the output control.
11. Place the mask comfortably on the “patient’s” face and instruct the “patient” to take slow,
deep breaths with occasional inspiratory hold as tolerated.
12. Periodically reassess vital signs and breath sounds throughout the treatment.
13. Modify technique and reinstruct the “patient” as needed based on “patient” response.
14. Terminate treatment after 15 to 30 minutes if significant adverse reactions occur, or when
sputum specimen has been obtained.
15. Reassess vital signs and breath sounds.
16. Encourage the “patient” to cough and expectorate sputum into specimen cup. Observe for
volume, color, consistency, odor, and presence or absence of blood.
17. Label the specimen container with “patient” identification and information (including
name, room number, identification number, physician, antibiotic therapy, source of
specimen, and date and time of collection) and deliver to the appropriate personnel.
Notify appropriate personnel of any adverse reactions or other concerns and make any necessary
recommendations or modifications to the “patient” care plan.
RE F E RE N CE S
1. Rubin, BK: Pediatric aerosol therapy: New devices and new drugs. Respir Care 56:1411–1423, 2011.
2. Woo, AH, Goetz, A, and Yu, VL: Transmission of Legionella by respiratory equipment and aerosol generating devices.
Chest 102:1586–1589, 1992.
2679_Ch15_211-236.indd 222 07/02/13 4:44 PM

Laboratory Report
CHAPTER 15: AEROSOL AND MEDICATION THERAPY
Name: Date:
Data Collection
EXERCISE 15.1 Small-Volume Nebulizers
E X E R C IS E 15 . 1. 1 ID E NT IFIC ATION OF COMPON EN T PARTS
A. ______________________________________________________
B. ______________________________________________________
C. ______________________________________________________
D. ______________________________________________________
E. ______________________________________________________
F. ______________________________________________________
G. ______________________________________________________
E X E R C IS E 15 . 1. 2 O P E R AT IO N OF A SMAL L -VOL UME N EBUL IZER
Observations
1 mL normal saline solution (NSS)/6 Lpm:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
3 mL NSS:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
10 Lpm:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
2 Lpm:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
2679_Ch15_211-236.indd 223 07/02/13 4:44 PM

6 mL NSS/6 Lpm:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
EXERCISE 15.2 Identification of Component Parts of Additional Delivery Devices
E XE RCI SE 1 5 .2 . 1 D R Y P O W D E R IN H A LE R (D P I) DEVICES AN D MEDICATION S
Available medication in DPI form:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Nonactive and dispersal agents:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
EXERCISE 15.3 Specialty Nebulizers
A. ______________________________________________________
B. ______________________________________________________
C. ______________________________________________________
D. ______________________________________________________
E. ______________________________________________________
F. ______________________________________________________
Comparison of a filtered nebulizer with a small-volume nebulizer:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Comparison of the HEART® and Circulaire® nebulizers with a small-volume nebulizer:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
2679_Ch15_211-236.indd 224 07/02/13 4:44 PM

Comparison of Aeroneb Pro® with a small-volume nebulizer:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Comparison of the PARI® nebulizer with a small-volume nebulizer:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Comparison of the AeroEclipse® BAN nebulizer with a small-volume nebulizer:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
EXERCISE 15.4 Aerosol Medication Administration
E X E R C IS E 15 . 4. 1 D R Y P O W D E R IN HAL ER (DPI) ADMIN ISTRATION
Medication and device used:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Chart your therapy:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
E X E R C IS E 15 . 4. 2 ME T E R E D -D OSE IN HAL ER (MDI) ADMIN ISTRATION
Propellant and nonactive ingredients:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
2679_Ch15_211-236.indd 225 07/02/13 4:44 PM

Chart your therapy:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
E XE RCI SE 1 5 .4 . 3 S MA L L -V O L U ME NE B U LIZ E R (SVN ) ADMIN ISTRATION
Chart your therapy:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
EXERCISE 15.5 Filtered Nebulizers
Observations
3 mL NSS/6 Lpm—density, particle size, and release of particles into the atmosphere:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
10 Lpm—density, particle size, and release of particles into the atmosphere:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
EXERCISE 15.6 Sputum Induction
Chart your therapy:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
2679_Ch15_211-236.indd 226 07/02/13 4:44 PM


1. Mr. Sullivan is a 55-year-old man who has just arrived at the emergency department. He has a documented history of
bronchitis and asthma. The physician has requested that you immediately assess the patient and make a recommenda-
tion for treatment. Your initial assessment reveals tachypnea, tachycardia, diaphoresis, audible wheezing, and the use
of accessory muscles.
A. What other bedside assessments would be important to perform at this time?
B. What specific treatment(s) would you recommend for this patient?
C. What specific medication and dosage would you suggest?
D. The physician disagrees with your suggestion and orders 5 mg of albuterol sulfate to be delivered every hour.
Briefly describe how you would handle this situation. What further recommendations would you make?
E. The initial aerosol therapy treatment has been started in the emergency department and has been administered
for 5 minutes. Monitoring of the patient indicates that the pulse rate has increased from 112 bpm to 140 bpm
and the audible wheezing appears to be improving. Describe your response to this situation.
F. The patient’s attending physician has been contacted and the patient is being admitted. The physician has written
additional orders for an Atrovent, Azmacort, and Intal inhaler two puffs each, to be administered q4h. In which
order should the medications be taken?
2. How do the Respirgard™/ISO-NEB™, and HEART® nebulizers differ from small-volume nebulizers? What medication
is delivered via Respirgard™/ISO-NEB™ nebulizers?
2679_Ch15_211-236.indd 227 07/02/13 4:44 PM

3. Given the following clinical scenarios, select the proper aerosol generator and aerosol delivery device:
A. A 60-year-old obtunded male who requires treatment with 0.5 mL Proventil and 3.0 mL NSS
B. An AIDS patient who requires pentamidine
C. A 35-year-old woman in the recovery room following abdominal surgery
D. A 55-year-old man with a size 8.0 tracheostomy tube
E. A 30-year-old patient with possible pneumonia requiring a sputum sample
F. A 4-month-old with respiratory syncytial virus
G. An 18-year-old asthmatic who is sensitive to the propellant in the MDI
H. A status asthmaticus patient admitted to intensive care and is not responding to q1 to 2h treatments.
The physician requests that you administer high-dose bronchodilator therapy.
2679_Ch15_211-236.indd 228 07/02/13 4:44 PM


STUDENT: DATE:
AEROSOL MEDICATION DELIVERY: NEBULIZED SOLUTIONS
PERFORMANCE LEVEL
PERFORMANCE RATING
Performance Level:
NA = Not applicable
Performance Rating:

2. Determines best medication delivery method (SVN, BAN, USN, Circulaire®, or other specialty nebulizer)
3. Checks label and verifies correct medication, dosage, and expiration date
4. Prepares medications per physician’s orders
5. Determines most appropriate patient interface to achieve therapeutic goals (mouthpiece, mask spacer, T-piece, tracheostomy collar,
ventilator in-line adaptor)

7. Selects appropriate propellant gas (air or oxygen)
8. Instructs patient to breathe normally with occasional slow, deep breaths and inspiratory hold as tolerated
9. Coaches and assists patient to modify technique as needed
10. Monitors vital signs throughout procedure
11. Measures peak flow before and after in asthmatic patients
12. Encourages and assists patient assists patient to cough; notes sputum production
13. Assesses treatment effectiveness
14. Terminates treatment if significant adverse reaction to medication occurs
FOLLOW-UP
16. Ensures patient rinses mouth if aerosolized steroid is administered
17. Shakes out nebulizer, rinses with sterile water only and/or dries with gas flow, and returns to treatment bag or clean container
18. Instructs patient and family on disinfection of nebulizer for home use
2679_Ch15_211-236.indd 229 07/02/13 4:44 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch15_211-236.indd 230 07/02/13 4:44 PM


STUDENT: DATE:
AEROSOL MEDICATION DELIVERY: CONTINUOUS BRONCHODILATOR NEBULIZATION
PERFORMANCE LEVEL
PERFORMANCE RATING
Performance Level:
NA = Not applicable
Performance Rating:

2. Checks label and verifies correct medication and expiration date

5. Selects appropriate propellant gas
6. Assembles continuous medication delivery device
7. Instills sufficient amount of medication and diluent
8. Coaches and assists patient as needed
10. Monitors vital signs throughout procedure
11. Encourages and assists patient cough; notes sputum production
FOLLOW-UP
2679_Ch15_211-236.indd 231 07/02/13 4:44 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch15_211-236.indd 232 07/02/13 4:44 PM


STUDENT: DATE:
AEROSOL MEDICATION DELIVERY: MDI, DPI
PERFORMANCE LEVEL
PERFORMANCE RATING
Performance Level:
NA = Not applicable
Performance Rating:

2. Determines best medication delivery method (MDI, DPI, spacer, or holding chamber)
3. Checks label and verifies correct medication, dosage, and expiration date
5. Determines most appropriate patient interface to achieve therapeutic goals (mouthpiece, mask, spacer, or holding chamber with
appropriate connector, ventilator, in-line adaptor)

7. Determines patient’s ability to perform procedure and follow directions
8. If MDI is used, ensures respiratory rate <25 breaths/min; if DPI used, verifies patient can inhale rapidly with inspiratory flow >60 Lpm
9. Removes dust cap, inspects actuator mouthpiece for any foreign objects
10. Shakes MDI, actuates one puff into air if more than 24 hours has elapsed since last use
11. Attaches MDI canister to spacer or holding chamber
12. Instructs patient as follows:
A. Exhale normally D. Waits at least 1 to 2 minutes between puffs
B. Take slow inspiration with coordination of MDI actuation E. Instructs patient to inhale more slowly if whistling sound is heard
from spacer
C. Perform maximal inhalation with inspiratory hold for 5 to
10 seconds if possible
13. If a ventilator interface is used, coordinates actuation with inspiratory phase of ventilator cycle
14. Coaches and assists patient as needed
A. Monitors vital signs throughout procedure B. Measures peak flow in asthmatic patients
16. Encourages and assists patient cough; notes sputum production
17. Terminates treatment if significant adverse reaction to medication occurs
FOLLOW-UP
19. Recaps mouthpiece when finished
20. Rinses mouth if aerosolized steroids are administered
21. Rinses mouthpiece and spacer with warm water at least daily
22. Determines MDI or DPI contents remaining
2679_Ch15_211-236.indd 233 07/02/13 4:44 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch15_211-236.indd 234 07/02/13 4:44 PM


STUDENT: DATE:
SPUTUM INDUCTION
PERFORMANCE LEVEL
PERFORMANCE RATING
Performance Level:
NA = Not applicable
Performance Rating:


3. Selects the proper equipment for obtaining a sputum sample:
A. USN
B. Bland aerosol
C. Other aerosol
4. Administers the therapy
5. Instructs the patient in the proper coughing techniques for obtaining a sputum sample
6. Instructs patient to expectorate into the sterile sputum cup
7. Ensures that the sample is from the lung and not naso/oropharynx
8. Labels the sample accurately and properly according to facility policy
9. Places the sample in a biohazard bag according to facility policy
10. Ensures that the proper laboratory request form is completed
11. Ensures that the sample is sent to the laboratory
FOLLOW-UP
2679_Ch15_211-236.indd 235 07/02/13 4:44 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch15_211-236.indd 236 07/02/13 4:44 PM

CHAPTER Hyperinflation
Therapy
Techniques
INTRODUCTION Hyperinflation techniques include a variety of basic respiratory care modalities, all of
which are designed to promote lung expansion and thereby prevent or reverse
atelectasis. This is accomplished by increasing transpulmonary pressure and inspiratory
volumes.1 Additional benefits of these modalities as components of bronchial hygiene
therapy include promoting a more effective cough, thereby improving mobilization of
secretions.
Incentive spirometry techniques, or sustained maximal inspiration (SMI), primarily

prevent atelectasis by mimicking or replacing the normal sigh mechanism and
encouraging the patient to take slow, deep breaths with an inspiratory hold. The patient
is encouraged to reach target inspiratory values predicted for the patient or previously
set as a baseline measurement. This can be done using a flow- or volume-oriented
incentive spirometry device.2 Intermittent positive-pressure breathing (IPPB) provides
short-term mechanical inflation to augment inspiratory volumes, deliver aerosol
medication, assist ventilation, and mobilize secretions.2 IPPB may be applied to
spontaneously breathing patients and to those with artificial airways3. It is not the first
choice for aerosol delivery or augmenting lung expansion when less expensive or less
invasive techniques can reliably accomplish these clinical outcomes.2
OBJECTIVES 1. Practice the communication skills needed for the instruction of patients in the techniques of
Upon completion of this sustained maximal inspiration and hyperinflation therapy.
chapter, you will be able to: 2. Perform and monitor incentive spirometry therapy using both flow and volume devices.
3. Practice medical charting for the therapeutic procedures of hyperinflation.
4. Identify and compare the component parts and controls of various IPPB devices.
5. Assemble and ensure proper function of IPPB equipment.
6. Perform and monitor volume-oriented IPPB therapy.
7. Evaluate the effects of various control manipulation on the volumes, I:E ratio, and Fio2
delivered by IPPB devices.
8. Analyze the effect of altered lung compliance and airway resistance on the volume delivered by
IPPB devices.
KEY TERMS
augment hypostasis thoracic pump
barotrauma hysteresis transpulmonary
bleb positive pressure pressure
bulla splint volutrauma
237
2679_Ch16_237-256.indd 237 07/02/13 4:44 PM

Exercises
F 50-psi air and oxygen sources F IPPB machines—Bird and Bennett
F Computerized lung simulator, optional F Masks
F Continuous positive airway pressure (CPAP) F One-way valve adaptors
mask and head straps F Oxygen analyzer with T-adaptor
F Disposable IPPB circuits F Peak flowmeter and disposable mouthpieces
F Disposable mouthpieces F Pillow
F Disposable nose clips F Positive end-expiratory pressure (PEEP)
F Down’s Flow or Whisper Flow generator valves
valves F Respirometers
F Flange (lip seal) F Stethoscopes
F Flow- and volume-based incentive spirometry F Stopwatch
devices F Test lungs
F Gloves F Tissues
F High-pressure hoses F Unit-dose normal saline vials
EXERCISE 16.1 INCENTIVE SPIROMETRY

EXERCISE 1 6.1.1 SUS TAIN ED MAX IM A L I N S P I R AT I O N P R E O P E R AT I V E I N S T R U C T I O N
Your laboratory partner 1. Gather the necessary equipment for this exercise:
will play the role of a Respirometer
preoperative patient who One-way valve adaptor
must be instructed in the Flow or volume incentive spirometer device
techniques of SMI. In clinical Pillow
situations, SMI is most 2. Wash or sanitize your hands and apply standard precautions and transmission-based
effective when the patient is isolation procedures as applicable.
instructed preoperatively. 3. Introduce yourself and your department. Explain the purpose of the therapy to the “patient”
and confirm that your “patient” understands.
4. Measure the “patient’s” preoperative inspiratory capacity and vital capacity using the
respirometer.
5. Assemble the incentive spirometer device as shown in Figure 16.1.
6. Instruct the “patient” on the use and frequency of the incentive spirometer device in the
following manner:
A. Exhale normally.
B. Insert the mouthpiece into your mouth and inhale slowly and deeply.
C. Hold your breath at the end of inspiration to the count of 10 (3 to 5 seconds).
D. Exhale normally.
E. Repeat the procedure 6 to 10 times per hour. Allow adequate recovery time between
breaths to prevent hyperventilation.
7. Instruct the “patient” on using a pillow to splint the incision postoperatively to minimize
pain during therapy, as shown in Figure 16.2.
8. Have the “patient” demonstrate the procedure to you.
9. Chart your “patient’s” preoperative evaluation and instruction on your laboratory report.
2679_Ch16_237-256.indd 238 07/02/13 4:44 PM

C H A P T E R 16 | H Y P E R I N FLAT I O N T HER AP Y TEC HNIQUES • 239
A B
Figure 16.1. Assembly and use of (A) volume incentive spirometer. (Courtesy of Voldyne, Sherwood, Davis, and Geck, St. Louis, MO.)
(B) A typical flow incentive spirometer. (Courtesy of Diemolding Corp., Diemolding Healthcare Division, Canastota, NY.)
Figure 16.2. Splinting an abdominal incision.
2679_Ch16_237-256.indd 239 07/02/13 4:44 PM

EXERCISE 1 6 .1 .2 IN CEN TIV E SPIR OM E T R Y P O S T O P E R AT I V E T H E R A P Y

Your laboratory partner 1. Gather the necessary equipment:
will play the role of a Stethoscope
postoperative thoracotomy Respirometer
patient who is in mild to One-way valve adaptor
moderate discomfort. Flow or volume incentive spirometer device
Pillow
isolation procedures as applicable.
3. Introduce yourself and your department.
4. Explain the purpose of the therapy to the “patient” and confirm that your “patient”
understands.
5. Measure the “patient’s” postoperative inspiratory capacity and vital capacity using the
respirometer. Your “patient” should simulate a decreased effort for this exercise.
6. Assemble the incentive spirometer device.
7. Assess patient progress by the following:
A. Pain medication schedule
B. Chest x-ray report from the “chart”
C. Change in “patient’s” temperature from the chart
D. “Patient’s” pulse and respiratory rate
E. Breath sounds on auscultation
8. Reinstruct the “patient” on the use and frequency of the incentive spirometer device in the
following manner:
A. Exhale normally.
B. Insert the mouthpiece into your mouth and inhale slowly and deeply.
C. Hold your breath at the end of inspiration to the count of 10 (3 to 5 seconds).
D. Exhale normally.
E. Repeat the procedure 6 to 10 times per hour. Allow adequate recovery time between
breaths to prevent hyperventilation.
9. Assist the “patient” in using the pillow to splint the incision postoperatively to minimize
pain during therapy.
10. Have the “patient” demonstrate the procedure to you.
11. Measure the achieved volume. For a volume-based device, observe the maximum
inspiratory effort achieved. For a flow-based device, the volume can be measured by
attaching the respirometer as shown in Figure 16.3.
12. Instruct the “patient” to cough. Observe for any sputum production. Auscultate the patient.
Figure 16.3. Measuring inspiratory volumes

on an incentive spirometer.
2679_Ch16_237-256.indd 240 07/02/13 4:44 PM

C H A P T E R 16 | H Y P E R I N FLAT I O N T H ER AP Y TEC HNIQUES • 241
EXERCISE 16.2 IDENTIFICATION OF INTERMITTENT POSITIVE-PRESSURE BREATHING

MACHINE COMPONENT PARTS AND CONTROLS
1. Obtain a Bird IPPB machine. Identify the component parts shown in Figure 16.4. Record the
model used and components on your laboratory report. (If the model used is not the same as
the one pictured, identify the controls of the model used and note how the controls differ.)
Expiratory (apnea) timer
Manual cycle rod
Large-bore tubing connection
Pressure chamber
Flow rate control
Gas inlet
Air mix plunger
Pressure manometer
Sensitivity
Ambient chamber
Pressure limit
Nebulizer/exhalation valve connection
2. Obtain a Bennett IPPB device. Identify the component parts shown in Figure 16.5. Record
the model used and components on your laboratory report.
Nebulizer—inspiration
Control pressure
Sensitivity
Air dilution
Nebulizer—expiration
System pressure
Peak flow
Pressure limit
Negative pressure
Expiratory time
Terminal flow
Rate
Bennett valve with dustcover
Accumulator
3. Remove the dustcover from the Bennett valve. Unscrew and carefully remove and examine
the valve. Replace it when you have completed your observation.
D
A B C E F
15
10
Figure 16.4. Components of a Bird IPPB machine. G H J I L
2679_Ch16_237-256.indd 241 07/02/13 4:44 PM

A B D
F
E
G
H
C
N J
I
M K
L
Figure 16.5. Components of a Bennett IPPB
machine.
EXERCISE 16.3 INTERMITTENT POSITIVE-PRESSURE BREATHING CIRCUITRY

ASSEMBLY
1. Attach the high-pressure hose to the IPPB machine and then to a 50-psi gas source.
2. Assemble an IPPB circuit as shown in Figure 16.6 and attach it to an IPPB machine.
3. Test the function of the machine by adjusting the pressure to maximum, manually cycling the
machine on, and aseptically occluding the outlet with a gloved hand or gauze. Ensure that
the machine cycles off. If it does not, examine it for any loose connections or a faulty
exhalation valve.
4. Attach a test lung to the circuit outlet (where the mouthpiece would normally be attached).
Increase the sensitivity adjustment until the machine automatically self-triggers, and then
decrease it slightly until auto-triggering stops. Now squeeze the test lung. The machine
should cycle on.
5. Adjust the pressure so that the machine cycles off at 20 cm H2O.
6. Adjust the flow so that inspiration takes approximately 2 seconds.
7. Attach the respirometer to the expiratory outlet of the circuit. Measure the volume achieved,
and record it on your laboratory report.
Manifold Exhalation valve

assembly driveline 39" tubing
Mouthpiece
Nebulizer
6" tube driveline
Figure 16.6. Assembly and components of an IPPB circuit. (Courtesy of Hudson Respiratory Care, Inc., Temecula, CA.)
2679_Ch16_237-256.indd 242 07/02/13 4:44 PM

EXERCISE 16.4 MANIPULATION OF INTERMITTENT POSITIVE-PRESSURE BREATHING

CONTROLS
EXER C ISE 16 .4 .1 V OL UME A N D I N S P I R AT I O N : E X P I R AT I O N R AT I O A D J U ST M E N T
Using a test lung attached to the IPPB circuit, make the following adjustments and observe the
results. Measure exhaled volumes using a respirometer attached to the expiratory outlet.
1. Record the current volume, flow, and sensitivity settings on the machine on your laboratory
report. Cycle the machine on, and record the achieved inspiratory volume on your laboratory
report.
After each change in Steps 2 through 5, note and record the pressure at end inspiration and
any change in inspiratory volume and time on your laboratory report.
2. Increase the pressure and cycle the machine on.
3. Set the pressure below the original setting.
4. Return the pressure to the original setting. Increase the flow setting.
5. Decrease the flow setting below the original settings.
After each adjustment in Steps 6 through 8, note and record the settings needed to achieve
this volume and the inspiratory time on your laboratory report.
6. Adjust the pressure and flow controls until a tidal volume of 500 mL is achieved.
EXER C ISE 16 .4 .2 S EN SIT I V I T Y C O N T R O L

Set the pressure and flow to 1. Increase the sensitivity control and note what happens when the test lung is squeezed. Note
the original settings. and record the negative pressure needed to initiate inspiration on your laboratory report.
2. Increase the sensitivity until the machine auto-triggers.
3. Decrease the sensitivity setting. Squeeze the test lung, and note and record on your
laboratory report the negative pressure needed to initiate inspiration.
EXER C ISE 16 .4 .3 F I O 2 C ONT R O L

1. Attach the IPPB machine to a 50-psi oxygen gas source.
2. Calibrate an oxygen analyzer and insert it between the inspiratory outlet and the test lung.
3. Adjust the rate control so that the machine automatically cycles on at a rate of 12 to 15
breaths per minute.
After each adjustment in Steps 4 through 9, allow the machine to cycle for several breaths
and record the FIO2 reading on the analyzer on your laboratory report.
4. Adjust the oxygen control on the IPPB machine to the “in,” or air mix off, position.
5. Adjust the oxygen control to the “out,” or air mix on, position.
6. Increase the pressure reading.
7. Decrease the pressure setting.
8. Increase the flow setting.
9. Decrease the flow setting.
2679_Ch16_237-256.indd 243 07/02/13 4:44 PM

EXERCISE 16.5 INTERMITTENT POSITIVE-PRESSURE BREATHING THERAPY
In this exercise, your 1. Gather the necessary equipment.

laboratory partner will act as 2. Wash or sanitize your hands and apply standard precautions and transmission-based
a patient. Because the isolation procedures as appropriate.
therapy will be given with 3. Introduce yourself and your department, explain the procedure, and confirm that your
aerosolized normal saline, “patient” understands.
caution should be used for 4. Assess the “patient” before therapy by measuring pulse rate and pattern, respiratory rate
any student with and pattern, and auscultation.
hypersensitive airways. 5. Measure the “patient’s” tidal volume, vital capacity, and peak flow rate.
6. Assemble the IPPB circuit with a mouthpiece and test the function. Adjust the settings
initially at a low pressure (approximately 10 cm H2O) and a moderate flow setting. Adjust
the sensitivity so that the machine is not auto-triggering.
7. Aseptically fill the nebulizer with a 3- to 5-mL unit dose of normal saline solution. If a
Bennett machine is used, adjust the nebulizer control to achieve a moderate mist.
8. Have the “patient” insert the mouthpiece into his or her mouth and maintain a tight seal. If
the “patient” has difficulty, nose clips or a mouth flange may be used.
9. Instruct the “patient” to inhale slightly until the machine triggers on and allow the machine
to augment inspiration. Note the volume achieved during inspiration.
10. Adjust the sensitivity if needed.
11. Adjust the pressure and flow until a maximum possible volume (at least two to three times
the tidal volume) is achieved during inspiration without “patient” discomfort.
12. Instruct the “patient” to breathe slowly to prevent hyperventilation.
13. Monitor pulse, respirations, and breath sounds during therapy. Observe the “patient” for
any adverse reactions.
14. At the end of the therapy, reassess the “patient’s” vital signs, breath sounds, vital capacity,
and peak flow.
15. Instruct the “patient” to cough. Note any sputum production. Assess volume, color,
consistency, and odor.
16. Disassemble the equipment, dispose of any infectious waste in the appropriate containers,
and wash or sanitize your hands.
18. Repeat the therapy using the mouth flange.
19. Repeat the therapy using a mask, as shown in Figure 16.7.
20. Repeat the therapy using an artificial airway, as shown in Figure 16.8.
Figure 16.7. Administration of an IPPB treatment

with a face mask.
2679_Ch16_237-256.indd 244 07/02/13 4:44 PM

C H A P T E R 16 | H Y P E R I N FLAT I O N T H ER AP Y TEC HNIQUES • 245
Figure 16.8. Administration of an IPPB treatment

via artificial airway.
EXERCISE 16.6 COMPUTERIZED LUNG SIMULATOR: EFFECT OF COMPLIANCE AND

RESISTANCE CHANGES ON INTERMITTENT POSITIVE-PRESSURE
BREATHING VOLUMES
The following exercise may 1. Adjust the lung simulator for normal compliance and resistance.
be performed if a 2. Adjust the IPPB machine to achieve a tidal volume of 700 mL. Record these settings on your
computerized lung simulator laboratory report.
is available. If not, an airway 3. Increase the airway resistance setting (or decrease the size of the endotracheal tube). Record
management trainer can be any changes in achieved tidal volume and inspiratory time on your laboratory report.
used with endotracheal 4. Return the resistance to normal. Decrease the compliance below normal on the lung
tubes of varying size to simulator (or manually restrict the expansion of the test lung). Record any changes in
simulate resistance changes achieved tidal volume and inspiratory time on your laboratory report.
and manual manipulation of 5. Increase the compliance above normal. Record any changes in achieved tidal volume and
a test lung to simulate inspiratory time on your laboratory report.
compliance changes.
R E FE R E N C E S
1. American Association for Respiratory Care: The AARC clinical practice guideline: Incentive spirometry. Respir Care 36:1402–1405, 1991.
2. Cairo, JM and Pilbeam, SP. Mosby’s Respiratory Care Equipment, ed. 8, Mosby, St. Louis, 2010.
3. American Association for Respiratory Care: The AARC clinical practice guideline: Intermittent positive pressure breathing: 2003 revision
and update. Respir Care 48(5):540–546, 2003.
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2679_Ch16_237-256.indd 246 07/02/13 4:44 PM
Laboratory Report
CHAPTER 16: HYPERINFLATION THERAPY TECHNIQUES
Name: Date:
Data Collection
EXERCISE 16.1 Incentive Spirometry
E X E R C IS E 16 . 1. 1 S U S TA INE D M AXIMAL IN SPIRATION PREOPERATIVE IN STRUCTION
Chart the preoperative “patient” evaluation and instruction below. Include the “patient’s” preoperative inspiratory, vital capacity, and
peak flow measurements.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
E X E R C IS E 16 . 1. 2 IN C E N T IV E S PIROMETRY POSTOPERATIVE THERAPY
Chart the postoperative treatment below as you would on a legal medical record.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
EXERCISE 16.2 Identification of Intermittent Positive-Pressure Breathing Machine

Component Parts and Controls
Bird Controls
Model of machine used: ________________________________________________________________________________________
A. _________________________________________________________________________________________________________
B. _________________________________________________________________________________________________________
C. _________________________________________________________________________________________________________
2679_Ch16_237-256.indd 247 07/02/13 4:44 PM

D. _________________________________________________________________________________________________________
E. _________________________________________________________________________________________________________
F. _________________________________________________________________________________________________________
G. _________________________________________________________________________________________________________
H. _________________________________________________________________________________________________________
I. _________________________________________________________________________________________________________
J. _________________________________________________________________________________________________________
K. _________________________________________________________________________________________________________
L. _________________________________________________________________________________________________________
Bennett Controls
Model of machine used: _______________________________________________________________________________________
A. _________________________________________________________________________________________________________
B. _________________________________________________________________________________________________________
C. _________________________________________________________________________________________________________
D. _________________________________________________________________________________________________________
E. _________________________________________________________________________________________________________
F. _________________________________________________________________________________________________________
G. _________________________________________________________________________________________________________
H. _________________________________________________________________________________________________________
I. _________________________________________________________________________________________________________
J. _________________________________________________________________________________________________________
K. _________________________________________________________________________________________________________
L. _________________________________________________________________________________________________________
M. _________________________________________________________________________________________________________
N. _________________________________________________________________________________________________________
Controls on other Bennett machines:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
2679_Ch16_237-256.indd 248 07/02/13 4:44 PM

EXERCISE 16.3 Intermittent Positive-Pressure Breathing Circuitry Assembly
Volume achieved: _____________________________________________________________________________________________
EXERCISE 16.4 Manipulation of Intermittent Positive-Pressure Breathing Controls
E X E R C IS E 16 . 4. 1 V O L U ME A ND IN SPIRATION : EXPIRATION RATIO ADJUSTMEN T
Original settings:
Pressure: ___________________________ Flow: ___________________________ Sensitivity: __________________________
Volume achieved: __________________________________ Inspiratory time: _________________________________________
Increased pressure setting:
Decreased pressure setting:
Increased flow setting:
Decreased flow setting:
500 mL:
Pressure setting: _______________ Flow setting: _______________________ Inspiratory time: __________________________
700 mL:
300 mL:
E X E R C IS E 16 . 4. 2 S E NS IT IV IT Y CON TROL
Increased sensitivity, negative manometer pressure reading: __________________________________________________________
Decreased sensitivity, negative manometer pressure reading: __________________________________________________________
E X E R C IS E 16 . 4. 3 F I O 2 C O N T R O L
Air mix in; FIO2: _______________________________________ Air mix out; FIO2: _________________________________________
Increased pressure; FIO2: _______________________ Decreased pressure; FIO2: _________________________________________
Increased flow; FIO2: _______________________________ Decreased flow; FIO2: _________________________________________
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EXERCISE 16.5 Intermittent Positive-Pressure Breathing Therapy
“Chart” the IPPB therapy as you would on a legal medical record.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
EXERCISE 16.6 Computerized Lung Simulator: Effect of Compliance and Resistance

Changes on Intermittent Positive-Pressure Breathing Volumes
Original settings:
Compliance: ___________________ Resistance: _____________________________ Pressure: __________________________
Flow: ____________________ Volume achieved: ________________________Inspiratory time: __________________________
Increased resistance:
Decreased compliance:
Increased compliance:

Scenario: Mr. Rodriguez is a 29-year-old man with quadriplegia as a result of a spinal cord injury. He has been having epi-
sodes of recurrent atelectasis in the right lower lobe (RLL).
1. What therapeutic hyperinflation technique would you recommend as most appropriate for this patient?
2679_Ch16_237-256.indd 250 07/02/13 4:44 PM

2. Mr. Rodriguez is noted to have a reduced inspiratory and vital capacity.
A. On the Bird IPPB machine, which control(s) could be adjusted to increase the volume achieved during therapy?
B. How would you adjust the setting of these control(s) for this purpose?
C. If a Bennett machine is used, which control(s) could be adjusted to increase the volume? How would the
control(s) be adjusted?
3. Mr. Rodriguez is having difficulty initiating inspiration during IPPB. Which control should be adjusted? How should it
be adjusted?
4. It is noted during IPPB therapy that the pressure gauge is rising very slowly during the first half of inspiration. What
control could be adjusted to correct this situation?
5. Mr. Rodriguez complains of light-headedness, paresthesias, and headache during incentive spirometry therapy. What is
the most likely cause and how would you correct this situation?
6. A patient with COPD who is breathing on hypoxic drive is undergoing an IPPB treatment to prevent impending respi-
ratory failure. How would you adjust the Fio2? Describe the difference in this adjustment between a Bird versus a
Bennett machine.
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7. You note that a Bird IPPB device is stuck in the inspiratory position. Identify three causes of this problem and what
you would need to do to correct each situation.
8. What types of patients would most benefit from incentive spirometry?
9. How can the effectiveness of incentive spirometry therapy be determined?
10. During IPPB therapy, a patient suddenly complains of a sharp, left-sided chest pain. She becomes cyanotic and dys-
pneic. How would you assess this patient’s condition and what actions should be taken?
11. A home care patient who has recently returned home after a surgical procedure complains that his incentive spirometer
is no longer working properly. Upon watching the patient perform the incentive spirometry procedure, you note
that the bellows does not move up with inhalation. What might be the possible cause of this and what would you
recommend?
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STUDENT: DATE:
INCENTIVE SPIROMETRY
PERFORMANCE LEVEL
PERFORMANCE RATING
Evaluator: Setting:
Performance Level:
NA = Not applicable
Performance Rating:

2. Determines the patient’s pain medication schedule and coordinates therapy as needed
3. Assesses and instructs the patient preoperatively if possible

5. Assesses vital signs, breath sounds, and chest x-ray
6. Instructs the patient in splinting if needed
7. Measures the VT, IC, and SVC with a respirometer
8. Instructs the patient to inhale slowly to inspiratory capacity; with a 3–5 second inspiratory hold if tolerated
9. Instructs the patient to repeat 6–10 times per hour
10. Coaches and assists the patient’s technique
11. Allows adequate recovery time between breaths to prevent hyperventilation
12. Evaluates and reinstructs the patient’s performance
13. Sets volume or flow rate goals
FOLLOW-UP
15. Ensures the IS device is within the patient’s reach
16. Periodically reassesses and reevaluates goals
2679_Ch16_237-256.indd 253 07/02/13 4:44 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
to modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch16_237-256.indd 254 07/02/13 4:44 PM


STUDENT: DATE:
INTERMITTENT POSITIVE-PRESSURE BREATHING (IPPB)

PERFORMANCE LEVEL
PERFORMANCE RATING
Evaluator: Setting:
Performance Level:
NA = Not applicable
Performance Rating:

2. Connects the circuit to the ventilator
3. Uses a filter on the machine outlet
4. Ensures integrity of connections (leak check)
5. Adjusts the ventilator to an acceptable baseline setting
A. Sensitivity (one thumb above auto-cycle)
B. Pressure 10–15 cm
C. Flow 10–15 Lpm
D. FIO2 or air mix

7. Evaluates chest x-ray and breath sounds
8. Measures the tidal volume, VC, and peak flow
9. Aseptically inserts the medication into the nebulizer
10. Instructs the patient in initiation of a positive-pressure breath
11. Applies nose clips, mouth flange, or mask as appropriate
12. Adjusts the ventilator to optimize treatment for VT; approx. 10–20 mL/kg ideal body weight
A. Instructs the patient not to exhale forcefully against exhalation valve
B. Instructs the patient to breathe slowly to prevent hyperventilation
C. Reinstructs the patient in technique as needed
13. Monitors exhaled volumes using a VENTI-COMP® bag or respirometer
14. Monitors vital signs, SpO2, and breath sounds
15. Evaluates the effectiveness of treatment
16. Assists and encourages the patient to cough; examines and collects sputum
FOLLOW-UP
2679_Ch16_237-256.indd 255 07/02/13 4:44 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
to modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch16_237-256.indd 256 07/02/13 4:44 PM

CHAPTER Bronchial
Hygiene: Chest
Physiotherapy
INTRODUCTION Increased mucus production or impaired cough ability from physical limitations can
overwhelm the body’s normal clearance mechanisms and lead to retained secretions.
Removal of retained secretions and improved cough effort are necessary to prevent
atelectasis and infection. Bronchial hygiene incorporates several techniques and
therapies, each with unique indications, contraindications, and hazards. These techniques
may be performed either manually or with the use of mechanically assisted devices. By
using gravity and mechanical vibration, secretions can be mobilized to a point at which
they may be spontaneously expectorated. If the patient does not have an adequate cough
effort, the respiratory care practitioner (RCP) must incorporate additional procedures to
remove the secretions or results may be less than optimal. The RCP’s responsibilities
also include instruction of patients and their families in these techniques for home
administration.
Bronchial hygiene techniques include the following:

1. Chest physiotherapy (CPT)
A. Postural drainage
B. Chest percussion
C. Expiratory vibration
2. Directed cough and manually assisted cough
3. Vibratory positive expiratory pressure (PEP) therapy and similar adjuncts
4. High-frequency chest wall oscillating (HFCWO) vest
5. Breathing exercises
6. Inspiratory resistive muscle training
Chest physiotherapy techniques will be discussed in this chapter. Breathing exercises and
adjuncts for airway clearance will be discussed in Chapter 18.
OBJECTIVES 1. Identify each lobe and segment of the lungs and the corresponding bronchi on a lung model.
Upon completion of this 2. Properly position and perform postural drainage, percussion, and vibration techniques for all
chapter, you will be able to: lung lobes and segments.
3. After reviewing x-ray reports and assessing physical examination results, perform chest
physical therapy techniques to the appropriate lobes and segments.
257
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KEY TERMS
abduction autofluorescence bronchoscopy (AFB) intracranial pressure (ICP) phlegm
adduction copious lobe segment
adjunctive fissure lobule sputum
apices inspissated orthostatic syncope
Exercises
F Adult mannequin F Pillows and pillowcases
F Bed sheets F Pulse oximeter and probes
F Blood pressure manometer and cuffs F Segmented lung model and tracheobronchial
F Foam wedge tree
F Hospital bed, electrical (if available) F Stethoscope
F Infant mannequin F Tilt table (if hospital bed is not available)
F Infectious waste disposal basin F Tissues
F Mechanical percussor F Towels
F Nonsterile gloves F Watch with second hand
F Percussion cups, various sizes
EXERCISE 17.1 IDENTIFICATION OF LUNG LOBES AND SEGMENTS
Using Figure 17.1 and Table 17.1, locate the lobes of the lung on a segmented lung model.
1 1
1
2
2 3
3
2
Figure 17.1. Lobes of the lung. Anterior Posterior
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C H A P T E R 17 | B R O N C H I A L H Y G I E N E : C H ES T P HY S IOTHER AP Y • 259
Using Figure 17.2 and Table 17.1, locate all of the lung segments on a segmented lung model.
Lateral Anterior
Medial Posterior
Figure 17.2. Lung segments.
Table 17.1 The Lobes and Seg-

Right Lung Left Lung
ments of the Lungs
Right Upper Lobe (RUL) Left Upper Lobe (LUL)
1 Apical 1–2 Apical-posterior
2 Posterior 3 Anterior
3 Anterior
Right Middle Lobe (RML)
4 Lateral 4 Superior lingula
5 Medial 5 Inferior lingula
Right Lower Lobe (RLL) Left Lower Lobe (LLL)
6 Superior 6 Superior
7 Medial basal 7–8 Anteromedial basal
8 Anterior basal 9 Lateral basal
9 Lateral basal 10 Posterior basal
10 Posterior basal
2679_Ch17_257-272.indd 259 07/02/13 4:45 PM

Using Figure 17.3 and Table 17.2, locate the major lobar and segmental bronchi on a model of
the tracheobronchial tree.
Figure 17.3. Tracheobronchial tree.
Table 17.2 The Major Lobar and

Right Lung Left Lung
Segmental Bronchi of the Tra-
cheobronchial Tree 1. Apical bronchus 1. Apical bronchus
2. Posterior bronchus 2. Posterior bronchus
3. Anterior bronchus 3. Anterior bronchus
4. Lateral bronchus 4. Superior bronchus
5. Medial bronchus 5. Inferior bronchus
6. Apical bronchus (lower lobe) 6. Apical bronchus (lower lobe)
7. Medial basal (cardiac) bronchus
8. Anterior basal bronchus 7.–8. Anterior basal bronchus
9. Lateral basal bronchus 9. Lateral basal bronchus
10. Posterior basal bronchus 10. Posterior basal bronchus
2679_Ch17_257-272.indd 260 07/02/13 4:45 PM

EXERCISE 17.2 POSTURAL DRAINAGE
NOTE: Because all of the following procedures for mobilization of secretions involve a patient
cough effort, local exhaust ventilation and personal protective equipment may be necessary to
prevent exposure to droplet nuclei in the clinical setting as well as in the lab with fellow students.
Standard precautions and transmission-based isolation procedures should be followed.
EXER C ISE 17 .2 .1 P OSTURA L D R A I N A G E P O S I T I O N I N G I N I N FA N T S

1. Using an infant mannequin, practice positioning the mannequin in your lap on a pillow as
2. Place the “infant” in each position to drain all lobes and segments, from most-dependent to
least-dependent lobes and segments (in infants, this is apices to bases).
NOTE: The baby should always be kept facing the practitioner to provide for direct visualization
and to permit a rapid response to changing levels of tolerance.
A B C
D E F
Figure 17.4. Postural drainage positions in infants. (A) Upper lobes, apical segment; (B) Upper lobes, posterior segment; (C) Upper lobes, anterior segment; (D) Lower
lobes, posterior segment; (E) Lower lobes, anterior segment; (F) Right middle lobe.
2679_Ch17_257-272.indd 261 07/02/13 4:45 PM

EXERCISE 1 7 .2 .2 P OSTURAL DR AIN A G E P O S I T I O N I N G I N A D U LT S

1. Using a laboratory partner or an adult mannequin, practice properly positioning a patient for
postural drainage on a bed or table.
2. Place the “patient” in each position shown in Figure 17.5 to drain all lobes and segments,
from most-dependent to least-dependent lobes and segments (in adults, this is from bases to
apices).
3. Use pillows and foam wedges to help maintain the proper positions.
NOTE: The practitioner should always be positioned facing the patient to provide for direct visu-
alization and to permit a rapid response to changing levels of tolerance. Roll the patient toward
you, not away.
A B
C D
E F
G H
I J
K L
Figure 17.5. Postural drainage positions in adults.
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EXERCISE 17.3 CHEST PERCUSSION
Practice the technique of 1. Remove your jewelry and wash or sanitize your hands. Apply standard precautions and
chest percussion as shown transmission-based isolation procedures as appropriate.
in Figure 17.6, using your 2. Cup your hands and allow for relaxed motion from the wrist. Do not stiffen your upper
laboratory partner as the arms. Rhythmically strike the designated area, alternating hands.
“patient.” 3. Practice first on your thigh. Listen for a hollow “clapping” or “galloping” sound. This sound
should be audible to someone not in the room, but should not cause pain or discomfort.
4. Position the “patient” for postural drainage (any position may be used for this exercise).
5. Perform chest percussion on the “patient” for at least 3 minutes. Remember the following
precautions:
A. Do not percuss over any buttons, zippers, or similar items that the subject may have on.
B. Do not percuss on bare skin. On an actual patient, use a towel or sheet over the
patient’s skin.
C. Avoid bony processes. Do not percuss on the spine, on clavicles, on scapulae, on breast
tissue, over areas of incisions, over areas of rib fractures, or below the rib margins.
6. Repeat the procedure using a mechanical percussion device (Fig. 17.7). Vary the speed and
force to observe the effects.
7. Repeat the procedure using percussion cups (Fig. 17.8), one in each hand. Small sizes are
available for children and infants, or a small face mask may be used by sealing the opening
with tape.
8. Baby G is going to be discharged tomorrow. With your laboratory partner acting as the
parent, instruct the “parent” on how to perform these procedures.
Figure 17.6. Chest percussion technique.
Figure 17.7. Mechanical percussor.

(Courtesy of General Physiotherapy,
Inc., St. Louis, MO.) Figure 17.8. Percussion cups.
2679_Ch17_257-272.indd 263 07/02/13 4:45 PM

EXERCISE 17.4 EXPIRATORY VIBRATION
Practice the technique of 1. Remove jewelry and wash or sanitize your hands. Apply standard precautions and
expiratory vibration, using transmission-based isolation procedures as appropriate.
your laboratory partner as 2. Place the “patient” in any position for postural drainage in which he or she is lying down.
the patient. 3. Place one hand over the other on the area to be vibrated, as shown in Figure 17.9.
4. Instruct the “patient” to take a deep breath and exhale slowly through pursed lips.
5. Apply a gentle vibrating motion during exhalation only. Your upper arm muscles should
tighten and allow transmission of the vibration to your hands. Do not shake the “patient.”
Repeat the vibration technique two or three times for each segment.
Figure 17.9. Expiratory vibration technique.
EXERCISE 17.5 CHEST PHYSIOTHERAPY TREATMENT
Perform a complete chest 1. Review any pertinent data on the “patient’s” chart, including physician’s orders or protocol,
physiotherapy treatment history and physical examination, diagnosis, x-ray results, and any precautions or possible
with postural drainage, contraindications to performing the procedure.
percussion, and vibration on 2. Wash or sanitize your hands and apply standard precautions and transmission-based
your lab partner or a human isolation procedures as appropriate.
patient simulator. 3. Coordinate therapy before meals and tube feedings or 11⁄2 hours after.
4. Introduce yourself to the “patient” and explain the procedure.
5. Assess the “patient” before therapy. Assessment should include the following:
Pulse
Respirations
Spo2
Blood pressure
Chest symmetry and expansion using palpation
Color
Level of dyspnea
Level of cooperation
6. Place the “patient” in each of the positions for drainage. (See Fig. 17.6.) Use pillows to
support the “patient” where necessary. Begin with the most dependent segments first.
NOTE: In an actual clinical situation, the patient would remain in each position for a minimum
of 3 to 15 minutes as tolerated for drainage.1 In special circumstances, the patient may remain in
drainage positions for longer periods of time.
7. Allow the “patient” to sit up and cough after each position. The “patient” may not produce
sputum immediately. The practitioner may need to check back with the “patient” at a later
time to determine any sputum production after the treatment.
2679_Ch17_257-272.indd 264 07/02/13 4:45 PM

8. Reassess the “patient’s” tolerance in each position by evaluating the following:
Pulse
Respirations
Spo2
Blood pressure
Color
Level of dyspnea
Level of cooperation
9. Note the volume, consistency, color, and presence or absence of blood in the sputum. Note
which positions are most productive.
R E FE R EN CES
1. American Association for Respiratory Care: AARC clinical practice guideline: Postural drainage therapy.
Respir Care 36:1418–1426, 1991.
2679_Ch17_257-272.indd 265 07/02/13 4:45 PM

2679_Ch17_257-272.indd 266 07/02/13 4:45 PM
Laboratory Report
CHAPTER 17: BRONCHIAL HYGIENE: CHEST PHYSIOTHERAPY
Name Date
Course/Section Instructor
Data Collection
EXERCISE 17.2 Postural Drainage
Identify the lobes and segments being drained in Figure 17.10.
A B
C D
Figure 17.10. Label the segments being drained in

E
the positions shown.
A: _________________________________________________________________________________________________________
B: _________________________________________________________________________________________________________
C: _________________________________________________________________________________________________________
D: _________________________________________________________________________________________________________
E: __________________________________________________________________________________________________________
EXERCISE 17.5 CHEST PHYSIOTHERAPY TREATMENT
Chart the therapy: _____________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
2679_Ch17_257-272.indd 267 07/02/13 4:45 PM


1. Identify normal airway clearance mechanisms in each of the following sections of the respiratory system:
A. Upper airway
B. Larynx
C. Tracheobronchial tree
D. Respiratory unit
2. Identify at least 10 conditions that would lead to ineffective secretion clearance.
3. Identify at least three hazards of coughing.
4. According to the AARC clinical practice guidelines (CPGs), how much sputum needs to be produced daily to be con-
sidered copious?
5. Explain the role of hydration in the mobilization of secretions.
2679_Ch17_257-272.indd 268 07/02/13 4:45 PM

6. What is meant by the expression “keep the good lung down?” What exceptions are there to this rule?
7. When is prone positioning indicated? Explain how it may help improve the patient’s condition.
8. Why is it recommended not to let the patient cough in the Trendelenburg position?
9. An 82-year-old woman with a history of osteoporosis who has recently undergone thoracic surgery has been producing
large amounts of purulent secretions. The physician has ordered CPT.
A. What recommendations or modifications would you suggest to accomplish this therapy?
B. While administering CPT, the patient’s telemetry tracing begins to show a long run of ventricular fibrillation. The
patient is stable with no signs of cyanosis or hypoxemia. You immediately stop the procedure and the ECG re-
turns to normal sinus rhythm. How would you explain this?
10. A 17-year-old girl with cystic fibrosis who has copious sputum production complains of dyspnea and shows signs of
mild cyanosis during CPT and postural drainage positioning in the Trendelenburg position.
A. What modifications on recommendations can be made to improve the patient’s tolerance of the procedure?
B. How would you monitor the effectiveness of these modifications?
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11. A 25-year-old man with quadriplegia has been experiencing recurrent atelectasis in the RML and RLL. The patient has
a tracheostomy tube in place and is being given enteral nutrition through a percutaneous endoscopic gastrostomy
(PEG) tube.
A. How would you assess what positions to place the patient in for CPT and postural drainage?
B. Describe the appropriate positioning in this situation.
C. What precautions must be taken with this patient prior to CPT and postural drainage?
2679_Ch17_257-272.indd 270 07/02/13 4:45 PM


STUDENT: DATE:
CHEST PHYSIOTHERAPY
PERFORMANCE LEVEL
PERFORMANCE RATING
Performance Level:
NA = Not applicable
Performance Rating:


3. Determines the lobes and segments to be drained by assessing CXR, progress notes, and breath sounds
4. Verifies that no relative or absolute contraindications exist; modifies the procedure accordingly
5. Coordinates therapy prior to meals and tube feedings or 1 to 11⁄2 hours after meals
6. Correctly positions the patient for segments to be drained, 3–15 minutes as tolerated
A. Positions self to always face the patient
B. Performs drainage beginning with the dependent lung segments first (age appropriate)
7. Performs percussion in the correct locations for 3–5 minutes as tolerated
A. Uses appropriate hand position, adjuncts such as palm cups or mechanical percussors
B. Uses appropriate light cover
C. Produces appropriate sound
D. Does not percuss over bone, incisions, jewelry, buttons, or below ribs
8. Performs expiratory vibration with pressure appropriate to patient tolerance
9. Assesses adequate ventilation and oxygenation during the procedure; adjusts oxygen therapy as needed during therapy; checks SpO2,
pulse, respirations, and blood pressure periodically throughout therapy
10. Encourages and assists the patient to cough in an upright position
NOTE: The patient should not be allowed to cough in a Trendelenburg position.
11. Repositions the patient prior to departure
12. Collects and examines sputum
FOLLOW-UP
13. Evaluates and recommends alternative procedures as applicable (PEP therapy, chest oscillating vest)
2679_Ch17_257-272.indd 271 07/02/13 4:45 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
to modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch17_257-272.indd 272 07/02/13 4:45 PM

CHAPTER Adjunct
Techniques for
Bronchial Hygiene
INTRODUCTION Mucus clearance is an essential component of managing chronic pulmonary diseases such
as cystic fibrosis, bronchiectasis, and chronic bronchitis. In addition to the pharmacological
regimen, breathing exercises, directed cough, and the use of adjunctive mucus clearance
devices help with the maintenance of good pulmonary hygiene. It is essential that the
respiratory care practitioner (RCP) have expertise in the use of these devices because it is
the RCP’s role to educate patients and caregivers in their proper use.
OBJECTIVES 1. Instruct and monitor a patient on coughing, splinting, and pursed-lip breathing.
Upon completion of this 2. Practice directed cough and manually assisted cough techniques to improve cough effectiveness
chapter, you will be able to: according to AARC clinical practice guidelines.
3. Perform vibratory PEP therapy according to AARC clinical practice guidelines.
4. Instruct and monitor a patient on diaphragmatic, thoracic expansion, and relaxation breathing
exercises.
5. Perform inspiratory muscle-training techniques.
KEY TERMS
forced expiratory intrapulmonic positive expiratory
technique (FET) percussion pressure (PEP)
intracranial pressure ventilation (IPV)
(ICP)
Exercises
F 50-psi compressed air gas source F Nonsterile gloves
F Adult mannequin F Nose clips
F Disposable mouthpieces F Pressure manometer
F Flowmeter F Pulse oximeter and probes
F Infectious waste disposal basin F Stethoscope
F Inspiratory force adaptors F Tissues
F Inspiratory-resistive muscle-training devices F Vibratory PEP devices: PEP mask, TheraPEP®,
F Maximum inspiratory pressure manometer acapella®, FLUTTER® valve
273
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EXERCISE 18.1 DIRECTED COUGH
Several techniques are available to help improve the patient’s cough effort. Practice patient in-
struction and monitoring of these techniques, using your laboratory partner as the patient. The
sequence of steps in a normal cough is illustrated in Figure 18.1.
EXERCISE 1 8.1.1 COUGH IN S TRUC TIO N

2. Introduce yourself to the “patient” and explain the purpose of an adequate cough effort.
3. Have the “patient” sit up in a chair or on the bed or table. Patients who cannot tolerate a
sitting position can use a side-lying position with knees bent (Fig. 18.2).
4. Instruct the “patient” to take a deep breath, followed by a slight breath hold, then a cough.
Have tissues and a waste receptacle readily available. Note the volume, consistency, color,
and presence or absence of blood in any sputum expectorated.
5. Using a pillow or your hands, instruct the “patient” on splinting of any painful areas. (See
Fig. 16.2.) Apply gentle pressure over the involved area before deep inspiration, and increase
pressure slightly during the forced expiratory phase of the cough. Use standard precautions
and transmission-based isolation procedures as appropriate.
Figure 18.1. Cough reflex. Inspiration Hold Compression Expulsion
Figure 18.2. Side-lying position for cough.
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C H A P T E R 18 | A D J U N C T T E C H N I Q U E S FO R BR ONC HIAL HY GIENE • 275
EXER C ISE 18 .1 .2 C OUGH A LT E R N AT I V E S

Some patients do not have 1. Wash or sanitize your hands. Apply standard precautions and transmission-based isolation
the capacity or tolerance for procedures as appropriate.
a single forceful cough. You 2. Introduce yourself to the “patient” and explain the purpose of the procedure. Have tissues
can teach these patients and a waste receptacle readily available.
alternative methods to 3. Instruct the “patient” in serial coughing techniques. Have the “patient” take a moderately
improve cough effectiveness, deep breath, followed by a slight breath hold. Then perform two or three short coughs, one
compensate for physical after another. Rest and repeat the procedure.
limitations, and provide 4. Instruct the “patient” in a forced expiratory technique (FET), or huffing maneuver.
voluntary control over the A. Have the “patient” take a moderately deep breath, followed by a short breath hold.
cough reflex. Then perform three short forced exhalations with an open glottis. The “patient” should
Instruct your laboratory make a huffing or “Ha ha ha” sound on exhalation. Follow this with a period of
partner in each of the relaxed, controlled diaphragmatic breathing.
following techniques. B. This can be assisted by self-compression of the chest wall by using a brisk adduction
movement of the upper arms1 also known as a “chicken breath,” as shown in Figure 18.3.
5. You can improve the cough effort by providing a manually assisted cough using epigastric
pressure or external lateral compression of the thoracic cage2 (Fig. 18.4).
A. Instruct the “patient” to take a moderately deep breath, followed by a short breath hold.
Apply gentle pressure to the epigastric region coordinated with the “patient’s” cough
effort, making sure to avoid the xiphoid area. This should not be done after meals.
B. Instruct the “patient” to take a moderately deep breath, followed by a short breath hold.
Apply pressure to the lateral thoracic cage coordinated with the “patient’s” cough effort.
NOTE: In a patient with a tracheostomy, a manual resuscitator bag can provide assisted deep in-
spiration in conjunction with manually assisted cough techniques, as shown in Figure 18.5.
Figure 18.3. “Chicken breath”

technique for use with huffing.
A B
Figure 18.4. Assisted cough techniques.
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Figure 18.5. Assisted cough in a tracheostomized patient.
EXERCISE 18.2 VIBRATORY POSITIVE EXPIRATORY PRESSURE (PEP) THERAPY
PEP mask therapy is a possible adjunct or alternative to postural drainage and percussion tech-
niques for bronchial hygiene.3,4 Many devices are now on the market to create vibratory PEP,
reverse atelectasis, and promote secretion removal.
EXERCISE 1 8.2.1 COMPAR E VIBRATO R Y P E P D E V I C E S

1. Obtain the following devices:
FLUTTER® valve (Fig. 18.6)
PEP mask valve (Fig. 18.7)
TheraPEP® device (Fig. 18.8)
acapella® device (Fig. 18.9)
2. Assemble each device and compare the components of each.
Figure 18.6. FLUTTER® valve. (Reprinted by permission of

Nellcor Puritan Bennett, Pleasanton, CA.)
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Figure 18.7. Components of a PEP mask system. (Courtesy

of Resistex®, Mercury Medical, Clearwater, FL.)
Figure 18.8. TheraPEP® device. (Courtesy of Smiths

Medical, a division of Smiths Group plc., London, UK.)
Figure 18.9. acapella® device. (Courtesy of

Smiths Medical, a division of Smiths Group
plc., London, UK.)
EXER C ISE 18 .2 .2 V IBR AT O R Y P E P T H E R A P Y

1. Obtain a PEP device and set it up with the pressure manometer in line.
3. Introduce yourself to the “patient” and explain the purpose of the procedure.
4. Assess the “patient’s” vital signs, mental function, skin color, and breath sounds.
5. Adjust the fixed exhalation orifice to the largest setting.
6. Have the “patient” sit upright with his or her elbows resting comfortably on a table.
7. Place the mask comfortably but tightly over the nose and mouth or adjust nose clips and
mouthpiece.
8. Instruct the “patient” to take a larger than normal breath (but not to total lung capacity)
and exhale slowly at an I:E ratio of 1:3 or 1:4.
9. Observe the pressure generated on the manometer during exhalation. Decrease the size of
the fixed orifice until 10 to 20 cm H2O pressure is generated during exhalation. Note the
“patient’s” response.
10. Instruct the “patient” to take 10 to 20 breaths followed by two or three huffs (FET). In
an actual clinical situation, this procedure would be repeated four to eight times for
10 to 20 minutes. Reassess the “patient” periodically.
11. Note the quantity, color, and consistency of any sputum expectorated. Note the presence or
absence of blood.
12. “Chart” the therapy on your laboratory report.
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EXERCISE 18.3 BREATHING EXERCISES
Using your laboratory partner 1. Wash or sanitize your hands and apply standard precautions and transmission-based
as the patient, instruct your isolation procedures as appropriate.
“patient” in the pursed-lip 2. Introduce yourself, and explain the procedure to the “patient.”
and abdominal breathing 3. Instruct the “patient” on the pursed-lip breathing technique (Fig. 18.10).
techniques. A. Have the “patient” take a deep breath through his or her nose.
B. Instruct the “patient” to exhale through pursed lips with a slow, steady exhalation at an
I:E ratio of at least 1:3.
4. Instruct the “patient” in abdominal breathing techniques.
A. Have the “patient” lie down. For initial instruction, a slight Trendelenburg position is
recommended.
B. Place one hand on the “patient’s” epigastric area and one hand on the upper chest, as
C. Ask the “patient” to sniff or pant to feel diaphragmatic movement.
D. Instruct the “patient” to take a slow, deep breath through the mouth and exhale through
pursed lips. Apply firm pressure during inspiration. The “patient” should push your
hand away by protruding the abdomen. The upper chest and shoulders should expand
but not move up.
E. Replace your hands with a light book or other object, and instruct the “patient” to
practice moving the book up on inspiration. A bag of rice or birdseed may be used for
this exercise.
F. The “patient” can eventually repeat the procedure in a more elevated position as
tolerated while sitting and walking, as shown in Figures 18.12, 18.13, and 18.14.
The following relaxation 5. Have the “patient” lying in bed with head flexed slightly forward, thoracic spine straight,
techniques and exercises can shoulders rotated inward slightly, elbows flexed, and hips and knees flexed.
be practiced at home on 6. Instruct the “patient” to perform the following maneuvers. The “patient” should close his or
yourself or with a partner as her eyes, take slow breaths, and attempt to relax the body part while holding each position
the patient. for a count of 10.
A. Turn head to right.
B. Turn head to left.
C. Raise head from pillow.
D. Push head into pillow.
E. Make a fist with both hands.
F. Open fists.
G. Bend wrists.
H. Extend wrists.
I. Bend elbows.
J. Straighten elbows.
K. Reach arms above head.
L. Return arms to sides.
M. Shrug shoulders.
N. Raise the left leg and then lower it.
O. Raise the right leg and then lower it.
P. Spread legs apart.
Q. Bring legs together.
R. Roll knees in.
S. Roll knees out.
T. Flex both ankles.
U. Extend both ankles.
V. Curl toes.
W. Straighten toes.
Figure 18.10. Pursed-lip breathing technique.
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Figure 18.11. Diaphragmatic breathing. A B
Figure 18.12. Abdominal breathing in the sitting position.
Figure 18.13. Abdominal breathing while standing.
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Figure 18.14. Breathing retraining while walking with oxygen.
EXERCISE 18.4 INSPIRATORY-RESISTIVE MUSCLE TRAINING
A patient usually performs 1. Wash or sanitize your hands and apply standard precautions and transmission-based
inspiratory-resistive muscle isolation procedures as appropriate.
training over a 6-week 2. Set up the device as shown in Figure 18.15 or Figure 18.16. A flow-resistive or threshold-
training period for resistive device may be used.
approximately 30 minutes 3. Measure the “patient’s” maximum inspiratory pressure using a pressure manometer.
per day with a gradual 4. Select the inspiratory-resistive device (colored caps or dial selector) with the largest opening
increase in workload.5 and apply it to the inspiratory port.
5. Attach the pressure manometer in line to the monitoring adaptor.
6. Place nose clips comfortably on the “patient’s” nose.
7. Have the “patient” make a tight seal around the mouthpiece.
8. Instruct the “patient” to inhale and exhale slowly through the mouthpiece.
9. Note the manometer pressure during inspiration. Adjust the inspiratory-resistive orifice until
you are using the resistor that achieves 30% of the “patient’s” MIP effort.
10. In a clinical situation, this would be repeated for 15 minutes twice daily.5
11. “Chart” the therapy on your laboratory report.
Figure 18.15. Flow-resistive inspiratory muscle-training device.
2679_Ch18_273-294.indd 280 07/02/13 4:45 PM

One-way Dial
valve selector
Monitoring/Oxygen
adapter
Body
Port
Figure 18.16. Threshold-resistive inspiratory
Mouthpiece
muscle-training device.
R E FE R E N C E S
1. American Association for Respiratory Care: AARC clinical practice guideline: Directed cough. Respir Care 38:495–499, 1993.
2. American Association for Respiratory Care: AARC clinical practice guideline: Postural drainage therapy. Respir Care 36:1418–1426, 1991.
3. Mahlmeister, M, et al: Positive expiratory pressure mask therapy: Theoretical and practical consideration and a review of the literature.
Respir Care 36:1218–1230, 1991.
4. American Association for Respiratory Care: AARC clinical practice guideline: Use of positive airway pressure adjuncts to bronchial hygiene
therapy. Respir Care 38:516–521, 1993.
5. Scanlan, C, et al (eds): Egan’s Fundamentals of Respiratory Care, ed. 9. Mosby, St Louis, 2010.
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2679_Ch18_273-294.indd 282 07/02/13 4:45 PM
Laboratory Report
CHAPTER 18: ADJUNCT TECHNIQUES FOR BRONCHIAL HYGIENE
Name: Date:
Data Collection
EXERCISE 18.2 Vibratory Positive Expiratory Pressure (PEP) Therapy
E X E R C IS E 18 . 2. 2 V IB R AT O R Y PEP THERAPY
“Chart” the therapy given below as you would on a legal medical record. Be sure to include all pertinent data and measurements.
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
EXERCISE 18.4 Inspiratory-Resistive Muscle Training
“Chart” the therapy given below as you would on a legal medical record. Be sure to include all pertinent data and measurements.
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________

1. Identify the possible hazards of PEP mask therapy. State at least one situation in which the procedure may be contrain-
dicated.
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2. A physician has ordered chest physical therapy on a postoperative craniotomy patient whose chart indicates that the
head of the bed must remain elevated 30°. Identify what modifications to therapy or recommendations you believe are
necessary in this situation, and explain why.
3. A 65-year-old woman with COPD has begun a breathing exercise regimen. What data (objective and subjective) would
indicate beneficial effects of this program?
4. You are the therapist caring for a 10-year-old patient with cystic fibrosis. Following the patient’s therapeutic regimen,
the physician wrote orders for the patient to use his PEP device. Although the patient uses the device at home, you re-
instruct the patient on its use. Upon exhalation, no pressure is seen on the manometer and upon palpation no chest
wall vibrations are felt with exhalation. What should be done to facilitate better use of the PEP device?
5. A patient using the TheraPEP® device has a set pressure measured on the manometer of 10 cm H2O. During the ther-
apy, you note that the pressure has suddenly increased to 25 cm H2O. What might be the problem and what should
be done?
6. You are instructing a patient with COPD on the use of the FLUTTER® valve. The patient insists that the device is
much more comfortable to use if it is held upside down. What is the problem with holding the FLUTTER® valve
upside down?
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STUDENT: DATE:
BREATHING EXERCISES
PERFORMANCE LEVEL
PERFORMANCE RATING
Performance Level:
NA = Not applicable
Performance Rating:


3. Assesses vital signs, SpO2, VC, peak flow, and MIP prior to instruction
4. Instructs the patient on the pursed-lip breathing technique (1:2 ratio, at least 1:3)
5. Performs a 6-minute walk
A. Walks with the patient on level ground for 6 minutes as tolerated
B. Has a wheelchair and oxygen device available at all times
C. Measures the distance walked
D. Monitors the SpO2, pulse, respiratory rate, and blood pressure
6. Instructs the patient in abdominal breathing techniques
A. Has the patient lay down in supine or slight Trendelenburg position as tolerated
B. Places one hand on the patient’s epigastric area and one hand on the upper chest
C. Asks the patient to “sniff” or “pant” to feel diaphragmatic movement
D. Instructs the patient to take a slow deep breath through his/her mouth and exhale through pursed lips
E. Applies firm pressure during inspiration
F. Replaces hands with a light book or other object and instructs the patient to practice
7. Repeats the procedure in a more elevated position
8. Repeats the procedure while sitting and walking, as tolerated
9. Instructs the patient in relaxation techniques
A. With the patient in a supine position, performs head-to-toe relaxation techniques
10. Instructs the patient in inspiratory muscle resistive training techniques (see PCE for Muscle Training)
FOLLOW-UP
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PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
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STUDENT: DATE:
DIRECTED COUGH
PERFORMANCE LEVEL
PERFORMANCE RATING
Performance Level:
NA = Not applicable
Performance Rating:


3. Instructs the patient in vibratory PEP therapy (See PCE for PEP Therapy)
A. Repeats four to eight times for 10–20 minutes
4. Instructs the patient in effective use of diaphragm and cough
5. Ensures forceful contraction of abdominal muscles
6. Instructs the patient in serial coughing techniques
7. Instructs the patient on the forced expiratory technique (FET), or huffing
8. Provides manually assisted cough
9. Applies pressure to the lateral thoracic cage coordinated with the patient’s cough effort
10. With tracheostomy, provides manually assisted deep inspiration utilizing a manual resuscitator bag in conjunction with manually
assisted cough techniques (quad cough)
11. Repeats the procedures as indicated/tolerated
12. Collects and examines sputum
FOLLOW-UP
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PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
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STUDENT: DATE:
POSITIVE EXPIRATORY PRESSURE (PEP) THERAPY/VIBRATORY PEP
PERFORMANCE LEVEL
PERFORMANCE RATING
Performance Level:
NA = Not applicable
Performance Rating:

2. Differentiates between different PEP and vibratory PEP devices (FLUTTER®, acapella®, PEP, TheraPEP®, EzPAP®)

4. Adjusts the exhalation orifice (PEP device) to the largest setting; adjusts the pressure reading (TheraPEP®); adjusts the compressed gas
flow (EzPAP®) or holds FLUTTER® level; for acapella®, adjusts the flow control to the open position
5. Positions the patient upright with elbows resting comfortably on a table
6. Places the mask comfortably but tightly over the nose and mouth or adjusts nose clips and mouthpiece
7. Instructs the patient to take a larger than normal breath and exhale slowly at an I:E ratio of 1:3 or 1:4
8. Observes the pressure generated on a manometer or gauge during exhalation; increases the pressure and/or vibration until 10 or 20 cm
H2O is generated during exhalation, or until an audible vibration can be heard
9. Instructs the patient to take 10–30 breaths followed by two or three huffs (FET); repeats four to eight times for 10–20 minutes
10. Reassesses the patient periodically and reinstructs if necessary
11. Encourages the patient to cough periodically; collects and examines sputum
FOLLOW-UP
2679_Ch18_273-294.indd 289 07/02/13 4:45 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
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STUDENT: DATE:
INSPIRATORY RESISTIVE MUSCLE TRAINING
PERFORMANCE LEVEL
PERFORMANCE RATING
Performance Level:
NA = Not applicable
Performance Rating:


3. Measures maximum inspiratory pressure and vital capacity
4. Selects an inspiratory-resistive device or dial selector with least resistance
5. Attaches the pressure manometer in line
6. Places nose clips comfortably on patient
7. Instructs the patient to exhale slowly through the mouthpiece, maintaining a tight seal
8. Notes the manometer pressure during inspiration, adjusts the inspiratory-resistive orifice to achieve 30% of MIP
9. Instructs the patient to repeat the exercise for 15 minutes, twice a day
10. Reassesses and reinstructs the patient as necessary
11. Encourages cough periodically; collects and examines sputum if applicable
FOLLOW-UP
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PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch18_273-294.indd 292 07/02/13 4:45 PM


STUDENT: DATE:
INTRAPULMONIC PERCUSSIVE VENTILATION (IPV)
PERFORMANCE LEVEL
PERFORMANCE RATING
Performance Level:
NA = Not applicable
Performance Rating:

2. Assembles equipment and verifies function

4. Selects the appropriate interface
5. Fills the reservoir with the prescribed solution or medication
6. Plugs in unit, turns on the unit, and adjusts the amplification and frequency to generate sufficient percussion and mist for effectiveness
7. Attaches the delivery device to the patient and ensures patient comfort
8. Reassesses the patient after application of the aerosol device
9. Collects sputum, labels, and sends to lab if indicated
FOLLOW-UP
2679_Ch18_273-294.indd 293 07/02/13 4:45 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
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CHAPTER Manual
Resuscitators and
Manual Ventilation
INTRODUCTION Manual resuscitators are adjunctive devices used to support short-term artificial
ventilation. Situations that may require their use include transport of ventilated patients,
application of positive-pressure breaths for hyperinflation and oxygenation during
suctioning, ventilator malfunction, and cough assisting. These devices can be used to
assist the spontaneously breathing patient and to fully support the apneic patient.
One of the most important uses of these devices is to support ventilation during a
respiratory or cardiac arrest. The respiratory care practitioner (RCP) is often one of the
first members of the health care team to arrive at a resuscitation event and is usually
responsible for airway maintenance and ventilation. In addition, manual resuscitators are
utilized for transporting patients requiring mechanical ventilation. It is imperative,
therefore, that the RCP understand the capabilities and functioning of manual
resuscitation devices and is able to troubleshoot them in an emergency situation.
Considerations for the RCP in selecting a resuscitation device should include the
following:
• Good “feel” to determine patient’s lung compliance
• Reservoir to ensure high FIO2 delivery
• Quick inflation and refill response
• Adequate ventilating volumes
• Ease of valve opening with the patient’s spontaneous breathing efforts
• Durability (if nondisposable)
• A valve that is easily cleaned
• Ease of assembly/disassembly
OBJECTIVES 1. Identify and differentiate the types of patient valves and how each operates during inspiration
Upon completion of this and expiration.
chapter, you will be able to: 2. Identify and discuss the advantages and disadvantages of self-filling and flow-filling bags.
3. Assemble and disassemble each type of device.
4. Demonstrate effective manual ventilation techniques with mouth-to-mask devices,
bag-valve-mask devices, and bag-valve resuscitators to an artificial airway and a
spontaneously breathing subject.
5. Explain the purpose of a pressure relief valve on a manual resuscitator and demonstrate its
operation.
6. Discuss the relationship between resistance, compliance, and the amount of positive pressure
necessary to accomplish ventilation.
7. Compare the variability in positive pressure, volume delivery, and Fio2 using different
ventilation techniques.
295
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KEY TERMS
capnometer insufflation resuscitation
hyperextend pop-off
Exercises
F Adaptors and connectors F Oxygen analyzers
F Computerized lung simulator or test lungs F Oxygen connecting tubing
F End-tidal PEco2 devices (colorimetric F Oxygen gas source
capnometers), adult and pediatric F Oxygen nipple adapters
F Intubated and nonintubated mannequins F Pressure manometers (disposable or
(adult, child, and infant) nondisposable)
F Laryngoscopes and blades F Respirometers
F Masks of various sizes F Spring-loaded, duckbill/diaphragm, and
F Mouth-valve-mask resuscitation unit (pocket diaphragm/leaf types of adult and neonatal/
mask) pediatric resuscitators
EXERCISE 19.1 ASSEMBLY AND DISASSEMBLY OF RESUSCITATORS
1. Select one of each type of resuscitator, as available: spring loaded, duckbill/diaphragm, and
diaphragm/leaf (Fig. 19.1). Study the type of valves and identify the manufacturers. Record
these on your laboratory report.
2. Disassemble the unit completely. This step will depend on which bag you are disassembling.
See the manufacturer’s specifications or refer to an equipment text if needed.
3. Reassemble the units. Make sure there are no leftover parts.
4. Test the unit for proper function by occluding the outlet and squeezing the bag. The bag
should hold pressure and volume until released. Record your observations on your
laboratory report.
5. Carefully observe the operation of the patient valve and oxygen inlet during inspiration and
expiration. Compare schematic representations of the operation of the valves during
inspiration versus expiration.
6. Repeat steps 2 through 5 for each bag selected.
7. Obtain a flow-filling ventilation device and assemble. Describe how this differs from
self-inflating bags on your laboratory report.
Figure 19.1. Nonrebreathing valves commonly

used with manual resuscitators.
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C H A P T E R 19 | M A N U A L R E S U S C I TAT O R S A N D M ANUAL V ENTILATION • 297
EXERCISE 19.2 PRESSURE RELIEF VALVES
1. Examine the pressure relief pop-off on the infant resuscitator. Record the set pressure release,
if available, on your laboratory report.
2. Occlude the outlet of the bag while squeezing it. Observe the function of the pressure pop-
off, and record your observations on your laboratory report.
3. Attach the bag to a lung simulator with a pressure manometer. Squeeze the bag slowly and
gently and note the highest pressure obtained during inspiration. Record this pressure on
4. With the bag still attached to the lung simulator with pressure manometer, squeeze the bag
forcefully and rapidly. Note the highest pressure obtained during inspiration. Record this
pressure on your laboratory report. How do these pressures compare to the ATSM standards?
5. Bypass the pressure relief mechanism so that it is nonfunctional according to standards. Refer to
the manufacturer’s literature or your instructor if you have any questions regarding how to do this.
6. Occlude the outlet of the bag while squeezing it. Observe the function of the pressure pop-
off, and record your observations on your laboratory report.
7. With the pressure relief disabled, attach the bag to a lung simulator with a pressure
manometer. Squeeze the bag slowly and gently and note the highest pressure obtained during
inspiration. Record this pressure on your laboratory report.
8. With the bag still attached to the lung simulator with pressure manometer, squeeze the bag
forcefully and rapidly. Note the highest pressure obtained during inspiration. Record this
pressure on your laboratory report.
EXERCISE 19.3 MEASUREMENT OF PRESSURES, STROKE VOLUMES, AND FIO2

EXER C ISE 19 .3 .1 MEASU R E ME N T W I T H O U T E FFE C T O F R E S I S TA N C E A N D C O M P L I A N C E
1. Attach a pressure manometer, in line between the patient valve and the endotracheal tube
connection, as shown in Figure 19.2. Place a respirometer and oxygen analyzer in line as learned
in Chapter 10. Make sure you have the oxygen turned up to 15 Lpm before proceeding to step 2.
2. Squeeze the bag gently with one hand several times, allowing for sufficient exhalation between
breaths. Record the pressure generated, the FIO2, and the volume delivered on your laboratory
report.
3. Repeat the exercise, except this time squeeze the bag vigorously with one hand. Record the
pressure generated, FIO2, and the volume delivered on your laboratory report.
4. Repeat the exercise, except this time squeeze the bag vigorously with both hands. Record the
pressure generated, FIO2, and the volume delivered on your laboratory report.
5. Disconnect the reservoir and repeat the measurements.
6. Reattach the reservoir.
7. Turn the liter flow down to 8 Lpm and repeat the one-handed squeeze and the two-handed
squeeze. Record the FIO2 delivered on your laboratory report.
8. Disconnect the reservoir and repeat the measurement. Record the FIO2 delivered on your
laboratory report.
9. Place a positive end-expiratory pressure (PEEP) valve on the exhalation valve of the
resuscitator (see Fig. 19.2) and repeat the measurements. Depending on the type of bag being
used, a special adaptor may be required. The PEEP valve may be preset or adjustable. Record
the type of valve used and the pressure setting on your laboratory report.
Figure 19.2. Monitoring equipment and PEEP valve in line with manual
resuscitator. (Courtesy of Instrumentation Industries Inc., Bethel Park, PA.)
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EXERCISE 1 9 .3 .2 MEASUR EMEN T W I T H E FFE C T O F R E S I S TA N C E A N D C O MP LI A N C E

The following exercise 1. Set the resistance at R = 5 (normal resistance) and the compliance at 0.10 L/cm H2O. Deliver
should be done using a lung three breaths and record the pressures and volumes on your laboratory report. If a lung
simulator, if available. If not, simulator is not available, use a standard test lung with an 8-mm endotracheal tube.
a test lung can be adapted to Increase the resistance to R = 50 (high resistance). Deliver three breaths and record the
approximate the resistance pressures and volumes on your laboratory report. If a lung simulator is not available, use a
and compliance changes. standard test lung with a 3-mm endotracheal tube.
2. Return the resistance to R = 5 (normal resistance) and change the compliance to 0.01 L/cm
H2O. Deliver three breaths and record the pressures and volumes on your laboratory report.
If a lung simulator is not available, use a standard test lung with an 8-mm endotracheal tube.
Place a rubber band around the center of the test lung.
EXERCISE 19.4 MOUTH-TO-MASK VENTILATION
1. Select a mouth-valve mask breathing device.

2. Select an adult, unintubated mannequin.
3. Place the head in the proper position using the head-tilt/chin-lift technique learned in BLS, as
4. Administer two breaths. Make sure you allow time for exhalation. Observe to see if the chest
rises and falls. Repeat until you achieve chest rise consistently.
5. Seal the mask over the nose using one hand only, without applying pressure on the mask
over the chin. Administer three breaths. Observe to see if the chest rises and falls. Repeat
until you achieve chest rise consistently. Record your observations on your laboratory report.
6. Place the head in a neutral position without using any airway opening techniques. Attempt to
ventilate. Reposition the head and repeat attempt to ventilate. Repeat until you achieve chest
rise consistently. Record your observations on your laboratory report.
Figure 19.3. Mouth-to-mask ventilation with a one-way valve.
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EXERCISE 19.5 MANUAL VENTILATION WITH MASK
1. Select adult, pediatric, and infant bag-valve-mask resuscitators.

2. Select infant, pediatric, and adult unintubated mannequins.
3. Attach the oxygen supply tubing to the oxygen source and turn to 15 Lpm.
4. Place the head of the adult mannequin in the proper position, using the head-tilt/chin-lift
technique.
5. Place the mask over the mouth and nose, using one hand to achieve a seal while maintaining
proper head position. This can be accomplished by using the last three fingers of your
nondominant hand to seal the lower portion of the mask while lifting up on the jaw and
using your thumb and index finger to secure the mask over the mouth and nose as shown in
Figure 19.4.
6. Administer ventilations at a rate of 12 to 20 breaths per minute for at least 1 minute. Make
sure to maintain a good seal and verify that the chest rises and falls with each breath, but do
not hyperinflate. Attempt ventilation with different masks and mannequins.
7. Repeat these steps using the child and infant mannequins and resuscitator at a rate of at least
20 breaths per minute for 1 minute. Avoid gastric insufflation. Remember: Do not
hyperextend the infant’s head to open the airway! Do not overventilate.
Figure 19.4. Proper hand position for resuscitator mask.
EXERCISE 19.6 MANUAL VENTILATION WITH AN INTUBATED MANNEQUIN
1. Select adult, child, and infant bag-valve-mask resuscitators.

2. Select adult, child, and infant intubated mannequins.
4. Using the adult mannequin, connect the patient connector on the resuscitator to the 22/15
connector on the endotracheal tube.
5. Squeeze the bag and give the mannequin three breaths, allowing for sufficient exhalation
after each breath. Record your observations on your laboratory report.
6. Repeat these steps using the child and infant mannequins and resuscitators.
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EXERCISE 19.7 MANUAL VENTILATION WHILE COMPRESSIONS ARE PERFORMED
1. Select adult, child, and infant nonintubated mannequins.

2. Select an adult bag-valve-mask resuscitator and the adult mannequin.
3. Go through the ABCs:
• Determine responsiveness.
• Call for help.
• Check Airway.
• Check for Breathing.
• Give two manual ventilations.
• Check Circulation.
4. With pulse present, continue rescue breathing at a rate of 12 to 10 per minute.
5. With no pulse present, have a partner perform cardiac compressions at a rate of 80 to
100 per minute.
6. Ventilate at 12 to 20 per minute in between the compressions for at least 1 minute.
7. Repeat these steps using the child and infant mannequins and resuscitators.
EXERCISE 19.8 ASSISTED MANUAL VENTILATION IN A SPONTANEOUSLY BREATHING

SUBJECT
1. Select an adult bag-valve-mask resuscitator. Apply standard precautions and transmission-

based isolation procedures as appropriate.
3. If human patient simulator is available, set the respiratory rate at 5 to 10 breaths per minute.
4. Using your laboratory partner as the subject, or a human patient simulator if available, place
the head in the proper position using the head-tilt/chin-lift technique.
5. Place the mask over the mouth and nose, using one hand to achieve a seal while maintaining
proper head position.
6. Allow your partner or human patient simulator to breath spontaneously through the bag.
Observe the valve operation.
7. Assist your partner’s or human patient simulator’s spontaneous ventilations. This is
accomplished by timing when you squeeze the bag to synchronize with the early inspiratory
phase. Administer moderately deep ventilations to achieve adequate chest rise. For your
laboratory partner’s comfort, do this only for every second or third breath.
8. If you are using a simulator, assist all breaths and attempt to ventilate in between assisted
breaths to achieve a total rate of 15 to 20 per minute.
9. Place the bags and masks in the designated dirty equipment area when this exercise is
completed.
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Laboratory Report
CHAPTER 19: MANUAL RESUSCITATORS AND MANUAL VENTILATION
Name: Date:
Data Collection
EXERCISE 19.1 Assembly and Disassembly of Resuscitators
Bag 1
Type of valve: _____________________________________________________________________________________________
Name/manufacturer: ________________________________________________________________________________________
Test function observations: ___________________________________________________________________________________
Bag 2
Type of valve: _____________________________________________________________________________________________
Name/manufacturer: ________________________________________________________________________________________
Bag 3
Type of valve: _____________________________________________________________________________________________
Name and manufacturer: ____________________________________________________________________________________
Flow-filling versus a self-inflating bag—Differences: __________________________________________________________________
____________________________________________________________________________________________________________
EXERCISE 19.2 Pressure Relief Valves
Set pressure: ________________________________________________________________________________________________
Observations while occluded: ___________________________________________________________________________________
Pressure achieved squeezing slowly: _____________________________________________________________________________
Pressure achieved squeezing forcefully: ___________________________________________________________________________
Compare pressures achieved to standards: _________________________________________________________________________
Observations with pressure relief disabled: _________________________________________________________________________
Pressure achieved with pressure relief disabled (slow): _______________________________________________________________
Pressure achieved with pressure relief disabled (forceful): ____________________________________________________________
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EXERCISE 19.3 Measurement of Pressures, Stroke Volumes, and FIO2
E XE RCI SE 1 9 .3 . 1 ME A S U R E ME NT W IT H O U T EF F ECT OF RESISTAN CE AN D COMPL IAN CE
One-Handed Squeeze, Gentle
Pressure: ________________________________________________ Volume: __________________________________________
FIO2 with reservoir: __________________________________________________________________________________________
One-Handed Squeeze, Vigorous
Pressure: ________________________________________________ Volume: __________________________________________
FIO2 without reservoir: _______________________________________________________________________________________
Two-Handed Squeeze, Vigorous
Pressure: ________________________________________________ Volume: __________________________________________
Flow at 8 Lpm
FIO2 with one-handed squeeze: ________________________________________________________________________________
FIO2 with two-handed squeeze: ________________________________________________________________________________
PEEP Valve Attachment
Type of valve: ______________ PEEP: ____________________ Pressure: ____________________ Volume: __________________
E XE RCI SE 1 9 .3 . 2 ME A S U R E ME NT W IT H E FF ECT OF RESISTAN CE AN D COMPL IAN CE
Normal resistance (Rp = 5)/Normal compliance (0.10 L/cm H2O): _________________________________________________________
Pressure: ________________________________________________ Volume: _________________________________________
Increased resistance (Rp = 50):___________________________________________________________________________________
Pressure: ________________________________________________ Volume: _________________________________________
Resistance (Rp = 5)/Decreased compliance (0.01 L/cm H2O): ___________________________________________________________
Pressure: ________________________________________________ Volume: _________________________________________
EXERCISE 19.4 Mouth-to-Mask Ventilation
Observation of one-handed squeeze, nose seal only: _________________________________________________________________
____________________________________________________________________________________________________________
Observations with head in neutral position: _________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
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EXERCISE 19.5 Manual Ventilation with Mask
Observations: ________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
EXERCISE 19.6 Manual Ventilation with an Intubated Mannequin
Observations: ________________________________________________________________________________________________
____________________________________________________________________________________________________________
Pressure relief setting: _________________________________________________________________________________________
Observations with occluded outlet: _______________________________________________________________________________
____________________________________________________________________________________________________________
Observations with pressure relief bypassed: ________________________________________________________________________
____________________________________________________________________________________________________________

1. Based on your observations, how do you know that you assembled the device properly in Exercise 19.1?
2. Identify at least three ways to increase the Fio2 delivered by a manual resuscitator.
-use the highest acceptable oxygen flow rate to the bag

-add a reservoir bag
-utilize the longest possible bag refill time
-increase the flow
-increase the FiO2
3. Identify at least two additional techniques that could be used to improve the patient’s Pao2 during manual ventilation.
use sodium sulfate solution

Add peep to the exhalation port(has a spring loaded mechanism )
squeezing the breath and holding it there. that is performing an inspiratory hold
4. What are the complications of manual ventilation?

-risk of hyperinflation can cause volutrauma, barotrauma bc u are pumping excessive pressures into the
lung
-hypo or hyperventilation of pt
-excessive air can go to stomach which would cause vomiting, aspiration of gastric content
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5. Compare and contrast adult ventilation with that of a neonate.
6. Identify at least three ways to initially assess the adequacy of manual ventilation.
Bilateral breath sounds on auscultation

ABGs
chest rise and fall
7. What limitations are there to ventilating with (a) a mask, and (b) an artificial airway?
8. What effect did changes in compliance and resistance have on the volumes and pressures delivered?
A. Increased compliance, decreased resistance
B. Increased compliance, increased resistance
C. Decreased compliance, increased resistance
D. Decreased compliance, decreased resistance
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9. Identify possible clinical situations/disorders that would imitate the changes in compliance and resistance as demon-
strated on the lung simulator in a patient requiring manual ventilation.
A. Normal compliance, normal resistance
B. Increased compliance, decreased resistance
C. Increased compliance, increased resistance
D. Decreased compliance, increased resistance
E. Decreased compliance, decreased resistance
10. You are asked to transport a mechanically ventilated patient to the radiology department and there is no mechanical
transport ventilator available. How should you prepare for the transport?
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STUDENT: DATE:
MANUAL VENTILATION
PERFORMANCE LEVEL
PERFORMANCE RATING
Evaluator: Setting:
Performance Level:
NA = Not applicable
Performance Rating:


3. Positions the patient’s head with the head-tilt/chin-lift maneuver or modified jaw thrust
4. Checks for breathing and pulse
5. Inserts the pharyngeal airway when available
6. Adjusts the liter flow to ≥15 Lpm or flushes and connects the oxygen tubing to the bag-valve-mask reservoir
7. Applies the mask to the patient’s face or 22-/15-mm adaptor to the artificial airway
8. Squeezes the bag to administer breaths, synchronizes with a spontaneous breath if present
9. Assesses the adequacy of ventilation and oxygenation by chest expansion, auscultation, vital signs, and SpO2
10. Repositions the head/mask as necessary
11. Reassesses the adequacy of ventilation and oxygenation and the presence of pulse periodically
12. Manually ventilates at 12–20 breaths per minute
FOLLOW-UP
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PERFORMANCE RATING:

COGNITIVE DOMAIN
to modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch19_295-308.indd 308 07/02/13 4:45 PM

CHAPTER Pharyngeal
Airways
INTRODUCTION The respiratory care practitioner (RCP) uses artificial airway devices to establish and
maintain airway patency, facilitate ventilation, and assist in the removal of secretions.
These devices include nasopharyngeal and oropharyngeal airways, laryngeal mask
airways (LMAs), and endotracheal and tracheostomy tubes. The RCP must be able to
select the appropriate airway, properly size and insert the airway, and maintain the
airway and ventilation.
Nasopharyngeal airways, sometimes called nasal airways or trumpets, are chiefly used to
facilitate the suctioning procedure. If the tube is too long it can interfere with the opening
of the epiglottis. Even proper placement can lead to epistaxis, otitis media, or sinusitis.
Oropharyngeal airways prevent the tongue from falling back into the oropharynx and
blocking the airway. They are mainly used to facilitate bag-valve-mask ventilation. The
RCP might also use them to maintain airway patency in patients who have adequate
respiratory effort but inadequate muscle tone or airway protection reflexes. If the airway
selected is too large, it can interfere with the epiglottis. If the airway is too small, it can
push the tongue back into the pharynx. Prehospital providers are occasionally using
tubes such as the esophageal-tracheal Combitube® (ETC) for difficult intubations.1 The
LMA has become increasingly popular as an alternative for difficult intubations in the
operating room as well as emergency department and prehospital settings. This device
provides a low-pressure seal around the glottis and may cause less trauma than
endotracheal intubation, but it does not reliably prevent aspiration.1 It is contraindicated
in nonfasting patients and in patients at high risk for aspiration. Its usefulness in an
emergency setting has not yet been completely evaluated. Disposable versions in various
sizes by different manufacturers are now available.
Endotracheal intubation and tracheostomy tubes are discussed in Chapters 22 and 23.
OBJECTIVES 1. Identify various types of airway adjuncts, including oropharyngeal and nasopharyngeal
Upon completion of this airways, LMAs, ETC, and accessories such as bite blocks, tongue blades, and oropharyngeal
chapter, you will be able to: suction devices.
2. Given a clinical scenario, select the most appropriate airway.
3. Measure a subject for the appropriate size airway.
4. Insert nasopharyngeal, oropharyngeal, LMA, and ETC airways into a mannequin or human
patient simulator.
309
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KEY TERMS
flange meatus perforation sinusitis
incisors naris pinna tragus
laryngospasm otitis media redundancy uvula
mandible
Exercises
F 4×4 gauze F Laryngeal mask airways (LMAs),
F 50-psi gas source various sizes
F Airway management trainers—adult, F Manual resuscitators with masks, various
pediatric, and infant sizes
F Alcohol prep pads F Nasopharyngeal airways, various sizes
F Brigg’s adapter and styles
F Cloth tape F Oropharyngeal airways—Guedel and Berman
styles, various sizes
F Esophageal-tracheal Combitube®
F Silicone spray lubricant
F Flowmeter
F Suction source and connection tubing
F Gloves—nonsterile, latex free, various sizes
F Tonsillar tip rigid catheter holder
F Goggles or face shields
F Water-soluble lubricant
F Hand sanitizer
F Yankauer (tonsillar tip) catheters,
F Human patient simulator (if available)
various styles
F Large-bore tubing
F Large-volume nebulizer
EXERCISE 20.1 IDENTIFICATION OF AIRWAY ADJUNCTS
Compare Figure 20.1, A through F, with the airways provided in the laboratory. Identify the type
of airway shown from the following list and record on your laboratory report.
Esophageal-tracheal Combitube® F
Laryngeal mask airway D
Nasopharyngeal adjustable flange airway E
Nasopharyngeal airway: trumpet style A
Oropharyngeal airway: Berman style B
Oropharyngeal airway: Guedel style
C
A B C
Figure 20.1. Airway adjuncts. ([E] Adapted from Rusch Inc., Duluth, GA with permission. [F] Courtesy of Kendall Healthcare Products Company,
Mansfield, MA with permission.)
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C H A P T E R 20 | P HARY NGEAL AIR WAY S • 311
D E F
EXERCISE 20.2 SELECTION AND INSERTION OF A NASOPHARYNGEAL AIRWAY
1. Select several sizes and styles of nasopharyngeal airways.

2. Determine the proper size airway to use on your laboratory partner, as shown in Figure 20.2,
by placing one end of the airway at the tip of the nose of your partner. Now pull the tube
toward the ear. If the tube goes past the opening of the ear, it is too large. The tube length
should equal the distance from the tip of the nose to the tragus of the ear plus 1 inch. Record
the size selected on your laboratory report.
isolation procedures as appropriate. Put on nonsterile gloves.
4. Lubricate the airway of the airway management training mannequin with the silicone spray.
NOTE: When inserting an airway into a patient, use a water-soluble lubricant.
5. Insert the airway into the external naris of the airway management trainer and push the
airway gently into place, following the anatomical curve as shown in Figure 20.3. Never
force an airway into place. If an obstruction is met, try the other naris.
6. The tip of the airway should be just past the uvula.
Figure 20.2. Sizing of a nasopharyngeal airway.
Figure 20.3. Insertion of a nasopharyngeal airway.
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EXERCISE 20.3 SELECTION AND INSERTION OF AN OROPHARYNGEAL AIRWAY
1. Select several sizes of oropharyngeal airways.

2. Determine the proper size airway for your laboratory partner, as shown in Figure 20.4, by
approximating the distance from the central incisors (front teeth) to the angle of the
mandible.1 Record the size and type selected on your laboratory report.
procedures as appropriate. Put on nonsterile gloves.
4. Insert the airway into the airway management trainer (Fig. 20.5). Open the mouth using a
cross-finger technique, and insert the airway into the mouth rotated 180° (upside down).
Continue to advance the airway until it is past the hard palate to the level of the uvula.
When it is almost completely in, rotate the airway into its final position so that the curvature
of the airway follows the natural curvature of the tongue, keeping it in place. The end of the
airway should be just beyond the base of the tongue.
5. Using a bag-valve-mask device, manually ventilate the mannequin with the airway in place
for at least 5 minutes. Ensure that the chest is rising and falling.
Figure 20.4. Sizing of an oropharyngeal airway.
A B C
Figure 20.5. Insertion of an oropharyngeal airway.
R E FE R E N C E
1. American Association for Respiratory Care: AARC clinical practice guideline: Management of airway emer-
gencies. Respir Care 40:749–760, 1995.
2679_Ch20_309-318.indd 312 08/02/13 4:51 PM

Laboratory Report
CHAPTER 20: PHARYNGEAL AIRWAYS
Name: Date:
Data Collection
EXERCISE 20.1 Identification of Airway Adjuncts
A: _________________________________________________________________________________________________________
B: _________________________________________________________________________________________________________
C: _________________________________________________________________________________________________________
D: _________________________________________________________________________________________________________
E: _________________________________________________________________________________________________________
F: _________________________________________________________________________________________________________
EXERCISE 20.2 Selection and Insertion of a Nasopharyngeal Airway
Size selected: ________________________________________________________________________________________________
EXERCISE 20.3 Selection and Insertion of an Oropharyngeal Airway
Size selected: _________________________________________ Type selected: _________________________________________

1. Why is a water-soluble lubricant used for inserting a nasal airway?
2. What complications might arise from the use of a nasopharyngeal airway?
nose bleeds, sinusitis, airway obstruction 4rm dried secretions
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3. What complications might arise from an improperly sized oropharyngeal airway?
airway obstruction if too small can block tongue

induce vomiting stimulate gag reflex
laryngospasm
4. What complications might arise from an improperly sized nasopharyngeal airway?
will induce if it goes all the way down gagging n vomiting

airway obstruction if it is too big
septal perforation
5. For each of the following scenarios, indicate what type of airway should be used. State your rationale.
A. Semiconscious patient in the recovery room:
Nasopharyngeal airway
B. An elderly, nonintubated patient who requires frequent suctioning:

Nasopharyngeal airway (or nasal trumpet if patient can maintain own airway)
C. A patient in cardiac arrest in the emergency department receiving basic life support (BLS):
Oropharyngeal airway until intubation can be performed

6. A patient is brought into the emergency department with an esophageal-tracheal Combitube® (ETC) in place. The phy-
sician wants you to intubate the patient with an endotracheal tube. What is the proper sequence of actions for replac-
ing the ETC?
7. You are called to the recovery room to administer 40% oxygen to a patient with a laryngeal airway in place. Describe
the equipment setup you would employ, including all connectors and adapters needed.
2679_Ch20_309-318.indd 314 08/02/13 4:51 PM

8. The patient in question 7 has regained consciousness and the laryngeal airway has been removed. What should you do
with the device at this time?
9. After the insertion of a pharyngeal airway, what should you monitor?
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STUDENT: DATE:
PHARYNGEAL AIRWAY INSERTION

PERFORMANCE LEVEL
PERFORMANCE RATING
Evaluator: Setting:
Performance Level:
NA = Not applicable
Performance Rating:


3. Assesses patient for the appropriate airway type (nasopharyngeal, oropharyngeal, esophageal-tracheal Combitube® [ETC], LMA)
4. Measures the patient for the appropriate size airway
5. Lubricates the airway if necessary
6. Positions the patient
7. Inserts the airway correctly
8. Assesses the patient for proper airway placement
9. Reinserts and adjusts the airway if necessary
10. Inflates the cuff if applicable
11. Reassesses the patient as needed
12. Secures airway
FOLLOW-UP
13. Ensures ventilation and oxygenation
2679_Ch20_309-318.indd 317 08/02/13 4:51 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
to modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch20_309-318.indd 318 08/02/13 4:51 PM

CHAPTER Suctioning
INTRODUCTION Suctioning is one of the most frequent procedures the respiratory care practitioner (RCP)
performs. It is achieved by insertion of a suction catheter through the nasal passages
(nasotracheal suction), by oral suctioning of the pharynx, or via an endotracheal tube.
Unfortunately, it is too often treated as a benign procedure, which it most definitely is
not. Even when it is performed properly, frequently encountered complications include
hypoxemia, cardiac dysrhythmias, nosocomial infection, atelectasis, mucosal trauma,
bronchospasm, pulmonary hemorrhage, elevated intracranial pressure, and patient
discomfort.1 Respiratory or cardiac arrest is always a distinct possibility. Nasotracheal
suctioning without an artificial airway may be one of the most dangerous procedures
performed by RCPs.
The RCP must perform proper patient assessment before suctioning a patient. Assessing
the need for suctioning can be accomplished by auscultation and palpation. The RCP
should perform suctioning prn only. Endotracheal suctioning may be required at some
minimum frequency to ensure artificial airway patency.1
RCPs should always be aware of the possible hazards and complications of these
procedures. The RCP should take care to ensure patient safety. Considerations include
using the proper size catheter, maintenance of aseptic technique, patient preparation
(including adequate preoxygenation before any suctioning event), and appropriate
pressure and time limitations.
OBJECTIVES 1. Identify the various types of suction devices and accessories, including Yankauer (tonsillar)
Upon completion of this catheter, Coudé or bronchitrach-L angle-tip endobronchial catheters, closed suction system
chapter, you will be able to: devices, and sputum traps.
2. Determine the proper suction catheter size for a given airway.
3. Demonstrate the proper aseptic donning of gloves and handling of the sterile contents of a
suction kit.
4. Aseptically perform nasotracheal suctioning on an airway management trainer using
appropriate personal protective equipment.
5. Perform endotracheal suctioning on an intubated airway management trainer using
appropriate personal protective equipment.
6. Perform tracheobronchial lavage during suctioning.
7. Collect a sputum specimen during suctioning.
8. Demonstrate the proper disposal of contaminated suction equipment.
9. Correlate the physical principles involved in suctioning, such as Poiseuille’s law, to suction
equipment and procedures.
319
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KEY TERMS
aspiration irrigation soluble
flush lavage vacuum
instillation lubricant
Exercises
F Airway management trainers (intubated and F Oxygen gas source and flowmeter
nonintubated) F Pulse oximeter and probes
F Basins F Silicone spray for mannequins or water-
F Biohazard transport bags soluble lubricant
F Closed suction catheter systems, various sizes F Sputum traps: Lukens and Dee Lee types
F Coudé or bronchitrach-L angle-tip endobron- F Sterile gloves
chial catheter F Sterile water or normal saline
F Disposal bags F Sterile water-soluble lubricant
F Goggles or face shields F Stethoscopes
F Human patient simulator (if available) F Suction catheter kits
F Manual resuscitator with mask F Suction source
F Nonrebreathing masks F T-piece and large-bore corrugated tubing
F Nonsterile disposable nonlatex gloves, F Unit-dose saline
various sizes F Yankauer (tonsillar tip) suction device
F Oxygen connecting tubing and nipple adapters
EXERCISE 21.1 SUCTION EQUIPMENT IDENTIFICATION
Compare the equipment provided in the laboratory with the equipment shown in Figure 21.1.
Identify each item and record it on your laboratory report.
Beaded-tip catheter B
Bronchitrach-L angle-tip endobronchial catheter A
Closed suction systems E
Dee Lee sputum trap D
Lukens sputum trap G
Murphy-tip catheter H
Suction connecting tubing
Thumb port connector I
“Y” connector J
Yankauer catheter, adult and pediatric
F
Figure 21.1. Suction equipment. ([G] From Ballard Medical

Products, Draper UT with permission.) A B
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C H A P TER 21 | S UC TIONING • 321
E
D F
G H I
J
2679_Ch21_319-334.indd 321 07/02/13 4:45 PM

EXERCISE 21.2 OROPHARYNGEAL SUCTIONING
2. Select a Yankauer (tonsillar) suction unit.
3. Put on nonsterile gloves.
4. Attach the Yankauer suction device to the end of the suction connecting tube.
5. Fill a basin with sterile water or normal saline.
6. Turn on the suction unit.
7. Test the unit by suctioning some of the sterile water or normal saline.
8. Introduce the Yankauer suction unit into the mouth of the mannequin and “suction” the
mouth of the mannequin.
9. Remove the unit from the mouth of the mannequin and clean it by flushing the unit and
the tubing.
10. Disconnect the unit and shut off the machine.
11. Cover the unit with the wrapper.
12. Remove your gloves and wash or sanitize your hands.
13. Dispose of all infectious waste in the proper receptacles.
EXERCISE 21.3 SUCTION KITS
This section is designed to 1. Select a suction kit.

practice aseptic technique in 2. Open the kit, making sure to maintain the sterility of the contents.
handling suction equipment. 3. Identify the components in the kit by visual inspection. Do not touch the contents.
The actual suctioning A. Record the brand used and contents contained on your laboratory report.
procedure will be practiced B. Depending on the brand of suction kit used, you might need to obtain additional items
in the next exercise. to complete the procedure. Compare the contents of your kit with the following list, and
obtain any extra items needed.
i. Two sterile gloves
ii. Sterile drape or other surface on which to place equipment
iii. Sterile basin
iv. Sterile water or saline
v. Sterile suction catheter
4. Put on the gloves using the procedure practiced in Chapter 3.
5. Open the sterile basin and fill the basin with the sterile solution using your nondominant
hand, if the basin is not prefilled. Keep in mind that if you are using a separate supply of
sterile solution, the container must also be handled aseptically. Mark the bottle of sterile
solution with the date and time when first opened. Discard the solution after 24 hours.
When opening the solution, place the bottle cap upside down aseptically on a clean surface.
6. Pick up the catheter with your dominant hand, keeping the catheter coiled. Remember
that this hand is considered to be the sterile hand and must touch nothing but the catheter.
7. While grasping the catheter in the palm of your hand, remove the glove from your dominant
hand by pulling the glove down and completely over the catheter.
8. Remove the other glove and discard the gloves into the proper garbage receptacle.
NOTE: For the purpose of laboratory practice, you may be reusing the suction kit and supplies.
If so, you should attempt to reorganize the kit in the way in which it was originally found.
2679_Ch21_319-334.indd 322 07/02/13 4:45 PM

EXERCISE 21.4 NASOTRACHEAL SUCTIONING
1. Wash or sanitize your hands and apply personal protective equipment (PPE) as appropriate.
2. Gather the necessary equipment: oxygen gas source, nonrebreathing mask, suction kit,
water-soluble lubricant, sterile water or normal saline, and suction machine.
3. Place the mannequin or human patient simulator in the Fowler’s position. In an actual
clinical situation, you should remove the pillow from behind the patient’s head and place
the head in a neutral position, avoiding hyperextension.
4. Assemble the nonrebreathing mask and oxygen.
5. Place the mask on the mannequin to hyperoxygenate the “patient” before suctioning.
Instruct the “patient” to take several deep breaths. Patients should be hyperoxygenated
before the suction event for at least 30 seconds.1
6. Assess the “patient” for adequate oxygenation, including color, respiratory rate and pattern,
heart rate and rhythm, and pulse oximetry.
7. Size, lubricate, and insert a nasopharyngeal airway into one naris (as performed in Chapter 20).
8. Turn on the suction unit.
9. Adjust the suction to the appropriate suction pressure (Table 21.1).
10. Open the water-soluble lubricant.
11. Open the suction kit and put on the gloves as in Exercise 21.2.
12. Connect the suction tubing to the thumb port connection or “Y” connector of the suction
catheter, as shown in Figure 21.1I and J.
13. Test the suction by placing the catheter into the sterile solution and occluding the thumb
port with the thumb of your nondominant hand. Readjust the suction pressure if necessary.
14. Apply the lubricant to the catheter by either squeezing the tube or packet into the palm of
your sterile hand and then pulling the catheter through the jelly to achieve lubrication, or
applying the lubricant to the sterile interior of the suction kit and then rotating the catheter
through it.
15. Without applying the suction, introduce the catheter into one of the nares, then slowly and
gently push the catheter until it advances into the oropharynx. Never force the catheter. If
an obstruction is met, attempt to pass the catheter through the other naris.
16. When you notice “fogging” of the catheter (condensation from exhaled air) or you hear a
change in the patient’s voice, you are entering the trachea. Obviously, this will not be
apparent on a mannequin. Continue introducing the catheter until an obstruction is met.
17. Once the obstruction is met, withdraw the catheter about one-half inch and apply the
suction with your thumb on the thumb port.
18. Continue to withdraw the catheter until it is removed. The withdrawal procedure and
application of suction should not take longer than 10 seconds.1 Frequently assess the
“patient” during the procedure.
19. Reapply the nonrebreathing mask with your nonsterile hand to reoxygenate the “patient.”
Patients should be reoxygenated for at least 1 minute before repeating the suction event.1
20. Flush the catheter and the tubing to clean it by suctioning the sterile solution through the
catheter.
21. Reassess the “patient” and repeat the procedure if needed after a sufficient time for
recovery.
22. Remove the nonrebreathing mask.
23. Turn the suction off.
24. Remove gloves and dispose of all equipment properly.
25. Wash or sanitize your hands.
Table 21.1 Recommended Suction

Wall Unit Portable Unit
Vacuum Pressures.
Adult –100 to –120 mm Hg (–150 mm Hg 10–15 in. Hg
maximum may be used)
Child –80 to –100 mm Hg 5–10 in. Hg
Infant –60 to –80 mm Hg 3–5 in. Hg
2679_Ch21_319-334.indd 323 07/02/13 4:45 PM

EXERCISE 21.5 ENDOTRACHEAL SUCTIONING
1. Select an intubated mannequin. Note the size of the endotracheal tube (ETT) being used by
looking at the underside of the 15-mm endotracheal tube adaptor. Record the size of the
endotracheal tube on your laboratory report.
2. Determine the size of the suction catheter to use. The outer diameter (OD) of the suction
catheter should not exceed one-half the size of the inner diameter (ID) of the airway.1
Because the airway is usually measured in millimeters and suction catheters are usually
measured in even-numbered French (Fr) sizes, a conversion is necessary. The formula will
result in the maximum recommended catheter size:
([0.5 ID mm × 3] + 2) = Fr suction catheter size
Alternatively, the following can be used:
([ETT ID mm × 2] – 2)
3. Record the size of the catheter selected on your laboratory report.
4. Wash or sanitize your hands and apply PPE as appropriate. Goggles, gloves, and gown are
recommended.1
5. Gather the necessary equipment: oxygen gas source, manual resuscitator, suction kit, sterile
water or normal saline, unit-dose saline, and suction machine.
6. Assemble the manual resuscitator and oxygen. The “patient” should receive
hyperoxygenation by 100% oxygen for at least 30 seconds before the suction procedure.1
You can accomplish this by several methods:
A. Increase the Fio2 to 100% on the oxygen delivery device, if possible.
B. A manual resuscitator may be used with maximum Fio2. Practitioners should ensure
that PEEP levels are maintained.1
C. If the “patient” is on a mechanical ventilator, the Fio2 can be adjusted to 100% or,
alternatively, some ventilators have a temporary oxygen enrichment mode available.
If this method is used, you must allow sufficient time for the circuit to be flushed with
the 100% oxygen before the suction event.
7. Regardless of the method selected, you must allow sufficient time for pre- and
postoxygenation so that the Spo2 nears 100%. Be sure you return the Fio2 to the
original setting when the procedure is completed.
8. Adjust the suction to the appropriate suction pressure.
9. Loosen the oxygen delivery device connected to the endotracheal tube.
10. Open the suction kit and put on the gloves as described in Exercise 21.2.
11. Connect the suction tubing to the other end of the suction catheter.
12. Test the suction unit as described in Exercise 21.4, step 13.
13. With your nonsterile hand, disconnect the oxygen delivery device attached to the
endotracheal tube and connect the manual resuscitator. Make sure that you place the
oxygen delivery device on a sterile field so as not to contaminate the device.
14. Hyperinflate and hyperoxygenate for at least 30 seconds. Assess the “patient” for adequate
oxygenation, including color, respiratory rate and pattern, heart rate and rhythm,
electrocardiogram (ECG), and pulse oximetry.
15. Quickly disconnect the oxygen source with your nondominant hand. Be sure not to place
the device in a soiled area.
16. Without applying the suction, quickly introduce the catheter into the tube, advancing the
catheter until it meets an obstruction.
17. Upon meeting an obstruction, withdraw the catheter about one-half inch and apply the
suction with your thumb on the thumb port.
18. Continue to withdraw the catheter, rotating it between your fingers, until it is removed. The
entire procedure should not take longer than 15 seconds. The withdrawal procedure and
application of suction should not take longer than 10 seconds. Frequently reassess the
“patient” during the procedure.
19. Reconnect the bag and hyperinflate and hyperoxygenate for at least 1 minute.
20. With your nonsterile hand, open one or two unit-dose saline vials.
NOTE: If secretions are particularly tenacious or difficult to remove, the “patient” may be
lavaged with saline to facilitate secretion removal. However, current Clinical Practice Guidelines
recommend that the routine instillation of normal saline not be performed.1
21. Disconnect the bag and aseptically instill the saline into the tube.
22. Reconnect and hyperinflate and hyperoxygenate for at least 1 minute.
23. Repeat the suction procedure.
24. Reconnect and hyperinflate and hyperoxygenate for at least 1 minute.
2679_Ch21_319-334.indd 324 07/02/13 4:45 PM

25. Return the “patient” to the proper oxygen delivery device and Fio2.
26. Flush the catheter and the tubing.
27. Disconnect the catheter from the connecting tubing. Remove gloves around the catheter as
described in Exercise 21.3, and dispose of all equipment properly.
29. Dispose of infectious waste. Wash or sanitize your hands.
EXERCISE 21.6 ENDOTRACHEAL SUCTIONING WITH A CLOSED SYSTEM
1. Select an intubated mannequin.

2. Wash or sanitize your hands and then put on nonsterile gloves.
3. Assemble the closed suction system, as shown in Figure 21.2, and attach to the patient
connection.
4. Connect the end of the system to the suction tubing.
5. Turn the suction unit on.
6. Turn the thumb control for suction to the “on” position.
7. Hyperoxygenate and hyperinflate the “patient” for at least 30 seconds. (Note that because
these units are most commonly used with a ventilator, hyperinflation and hyperoxygenation
already take place through the ventilator and replace this step.)
1. 6.
Place cap on either side of To lavage: Grasp T-piece
T-piece (opposite ventilator with one hand and advance
circuit connection). catheter with the other until
desired depth is achieved.
Instill saline solution through
the irrigation port. Saline
solution may now be pin-
pointed at the source of
secretions.
2. 7.
Attach control valve to the To suction: Grasp control
suction canister inlet tube. valve and apply pressure
intermittently. (Note: Minimal
thumb pressure will activate
suction, but maximum
suction is achieved when
valve is fully depressed.)
3. 8.
Prior to patient attachment, Withdraw and rotate catheter
turn on wall suction and set with one hand positioned on
suction at desired level while control valve while the other
depressing control valve. remains firmly grasping the
(Note: Initially, control valve T-piece/connector.
must be snapped sharply to
activate plunger.)
4. 9.
Attach T-piece to ventilator Retract catheter until blue
circuit. If desired, place flex catheter mark is visible in the
tube between circuit and sleeve. (Note: Do not over-
T-piece. extend the catheter.)
5. 10.
Attach T-piece to endo/trach Flush the catheter by
tube connector. If desired, instilling solution through
attach T-piece to swivel the irrigation port while
connector then attach to applying suction.
endo/trach tube.
Turn off wall suction.
Figure 21.2. Assembly of a closed suction system. (Courtesy of Smiths Industries Medical Systems, Keene, NH.)
2679_Ch21_319-334.indd 325 07/02/13 4:45 PM

8. Assess the “patient” for adequate oxygenation, including color, respiratory rate and pattern,
heart rate and rhythm, ECG (if available), and pulse oximetry.
9. Introduce the catheter into the airway by sliding it through the plastic sheath until
resistance is met.
10. Withdraw the catheter about one-half inch and apply suction as you withdraw the catheter
completely, pulling it straight out. Make sure that the tip is visible past the T connection.
Reassess the “patient” frequently during the procedure.
11. Reoxygenate and hyperinflate for at least 1 minute. Repeat the procedure if necessary.
12. Clean the catheter. Some brands have an irrigation port that allows you to inject saline and
flush the catheter. Refer to the manufacturer’s package insert for brand-specific instructions.
13. Make sure the thumb suction control is returned to the “off” or locked position when
finished.
EXERCISE 21.7 OBTAINING A SPUTUM SAMPLE
1. Repeat all the steps in Exercise 21.4, except make sure that you have put a sputum trap in
line as shown in Figure 21.3. Do not perform the lavage procedure.
2. After completing the procedure, disconnect the trap from the suction connecting tube. Seal it
by interconnecting the tubing to the trap inlet.
3. Label the sample with the following information, and record this information on your
laboratory report.
A. “Patient” name and identification number
B. Room number
C. Date and time
D. Type or source of sample
4. Place in biohazard transport bag with the “lab slip.”
5. Notify the “nurse” that the sample has been obtained.
Figure 21.3. Assembly of suction-sputum trap equipment.
RE F E RE N CE
1. American Association for Respiratory Care: AARC clinical practice guideline: Endotracheal suctioning of mechanically ventilated patients
with artificial airways 2010. Respir Care 55:758–764, 2010.
2679_Ch21_319-334.indd 326 07/02/13 4:45 PM

Laboratory Report
CHAPTER 21: SUCTIONING
Name: Date:
Data Collection
EXERCISE 21.1 Suction Equipment Identification
A: _________________________________________________________________________________________________________
B: _________________________________________________________________________________________________________
C: _________________________________________________________________________________________________________
D: _________________________________________________________________________________________________________
E: _________________________________________________________________________________________________________
F: _________________________________________________________________________________________________________
G: _________________________________________________________________________________________________________
H: _________________________________________________________________________________________________________
I: _________________________________________________________________________________________________________
J: _________________________________________________________________________________________________________
EXERCISE 21.3 Suction Kits
Brand used: _________________________________________________________________________________________________
Contents: ___________________________________________________________________________________________________
EXERCISE 21.5 Endotracheal Suctioning
Size of endotracheal tube: ______________________________________________________________________________________
Size of the suction catheter (Show your work): _______________________________________________________________________
____________________________________________________________________________________________________________
EXERCISE 21.7 Obtaining a Sputum Sample
LABEL INFORMATION
Patient name: __________________________________________________ ID#: _________________________________________
Date: ________________________________________________________ Time: _________________________________________
Type of sample: _______________________________________________ Room: _________________________________________
2679_Ch21_319-334.indd 327 07/02/13 4:45 PM


1. Identify at least three hazards and complications of suctioning that are unique to the nasotracheal route.
2. Contrast the dysrhythmias one would expect as a result of vagal stimulation during the suctioning procedure versus
those that would result from hypoxemia.
vagal stimulation would result in bradycardia or cardiac arrest.

Hypoxemia is more likely to cause tachycardia and ectopy such as premature ventricular
contractions/beats
3. Differentiate between mucus, sputum, and phlegm.
4. Is sputum normally considered a high-risk fluid for the transmission of bloodborne pathogens? Why or why not?
5. What is the rationale for PPE use while performing suctioning?
6. Given the following scenarios, identify all possible causes of the problem and offer at least two alternative solutions to
correct each problem.
A. You turn on an electrical suction machine and it does not work.

Check to see if it is plugged in, Double check to see if you turned it on,Change
outlets and see if another one works.Check cord for frays or tears and replace
machine if needed.
B. The suction is lost while suctioning a patient.
discontinue suction, reoxygenate pt and ventilate

then check equipment, connections and start over
2679_Ch21_319-334.indd 328 07/02/13 4:45 PM

C. You cannot get suction from a wall suction regulator.
Make sure the quick connect is secured.
Check that the suction control is turned on.
Check another outlet to see if it works
D. While attempting to suction an adult patient with an endotracheal tube, you cannot advance the catheter more
than 5 inches. tube may be obstructed, kinked, or the patient may be biting down.
Make sure the patient is not biting, or use a bite block.
Make sure you can ventilate the patient
Attempt gently to reposition the endotracheal tube slightly
E. After suctioning a patient, you hear a honking or high-pitched sound coming from the endotracheal tube.
tube may be obstructed, take material out
7. Calculate the maximum catheter sizes that can be used (Show your work):
A. ID 4.0-mm tracheostomy tube
B. ID 6.0-mm endotracheal tube
C. ID 7.5-mm endotracheal tube
D. ID 10-mm tracheostomy tube
8. A patient is suffering from hypoxemia, dysrhythmias, and bronchospasm during suctioning. Identify what methods
you would use to assess the patient’s status during suctioning and describe what precautions should be taken to prevent
each of the hazards mentioned.
Patient assessment should include observation of color and comfort level, ECG monitoring,
pulse oximetry, and auscultation.
Hypoxemia and dysrhythmias can be prevented by adequate preoxygenation to 100% fiO2
and hyperinflation. Correct suction pressures and catheter size will reduce hypoxemia.
Gentle suctioning pressures and dont send the catheter all the way in will prevent
dysrhythmias and bronchospasm from vagal stimulation. Bronchodilator therapy may also
be indicated.
9. What are the advantages of a closed suction system? When should it be employed? What is its role in controlling
ventilator-associated pneumonia?
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2679_Ch21_319-334.indd 330 07/02/13 4:45 PM

STUDENT: DATE:
ENDOTRACHEAL SUCTIONING
PERFORMANCE LEVEL
PERFORMANCE RATING
Evaluator: Setting:
Performance Level:
NA = Not applicable
Performance Rating:


3. Adjusts vacuum pressure to age-appropriate level
4. Attaches sputum trap, if required
5. Preoxygenates/hyperinflates patient using manual resuscitation bag, ventilator set to 100% suction, or nonrebreathing mask (spontane-
ously breathing patient without airway) for 30–60 seconds until SpO2 is 100%
6. Inserts catheter in airway; withdraws slightly if resistance met
7. Aspirates the airway on withdrawal only with a gentle rotating motion (continuous or intermittent suction may be applied)
8. Ensures that aspiration lasts no longer than 10 seconds
9. Maintains aseptic technique throughout the procedure
10. Monitors the patient for adverse reactions
11. Oxygenates the patient following aspiration until stabilized
12. Repeats as necessary
13. Returns O2 therapy to previous level
FOLLOW-UP
15. If in-line closed suction used, ensures that black line is pulled out of the airway adaptor and locks the thumb port device
16. Turns off the suction gauge
2679_Ch21_319-334.indd 331 07/02/13 4:45 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch21_319-334.indd 332 07/02/13 4:45 PM


STUDENT: DATE:
NASOTRACHEAL SUCTIONING
PERFORMANCE LEVEL
PERFORMANCE RATING
Evaluator: Setting:
Performance Level:
NA = Not applicable
Performance Rating:


3. Adjusts vacuum pressure to an age-appropriate level
4. Ensures that oxygenation device is available
5. Lubricates the nasal airway and inserts into a patent naris
6. Lubricates the suction catheter and inserts the catheter into the nasal airway at the appropriate distance
7. Assesses the catheter entry into the trachea (cough, change in voice, fogging)
8. Applies suction <10 seconds upon withdrawal with gentle rotating motion, 15 seconds maximum for entire event
9. Reoxygenates the patient following aspiration for at least 1 minute
10. Monitors the patient for adverse reactions and stops the procedure if necessary
11. If laryngospasm occurs, attaches the suction catheter to an oxygen source (does not remove) and applies manual ventilation
12. Examines sputum, collects if indicated
13. Repeats as necessary
FOLLOW-UP
14. Repositions the patient
15. Returns O2 therapy to the previous level
16. Turns off the suction gauge when finished
2679_Ch21_319-334.indd 333 07/02/13 4:45 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch21_319-334.indd 334 07/02/13 4:45 PM

CHAPTER Endotracheal
Intubation
INTRODUCTION Previous chapters discussed how to manage the airway without inserting an artificial
airway into the trachea. However, in some situations, a patient’s life may depend on the
ability of an individual to recognize the need for intubation of the trachea. That individual
is often the respiratory care practitioner (RCP). The RCP must be able to place and
maintain the airway properly and recognize the clinical situations in which one airway is
preferred over another. The AARC Clinical Practice Guideline for management of airway
emergencies emphasizes the need for the RCP to be able to identify, use, and maintain
the equipment necessary for intubation.1 Intubation of the trachea is an advanced skill
that requires extensive practice. One does not become proficient in intubation by
completing these exercises. Skill competency requires further practice in an environment
such as an operating room.
OBJECTIVES 1. Identify, select, prepare, and correct malfunctions of equipment necessary for endotracheal
Upon completion of this intubation of the infant and adult.
chapter, you will be able to: 2. Identify the different types of endotracheal tubes, component parts, and tube markings.
3. Assess the potential difficulty of intubation using the Mallampati classification.2,3
4. Test an artificial airway for cuff leaks.
5. Insert an orotracheal tube into an infant, a pediatric, and an adult airway management
trainer.
6. Remove an esophageal or tracheal Combitube® tube airway after intubation.
7. Manage and remove a laryngeal mask airway (LMA) in a postoperative recovery situation.
8. Insert a nasotracheal tube into an adult airway management trainer using direct vision and
blind technique.
9. Verify the proper positioning of an artificial airway and secure it in place.
10. Apply infection control guidelines and standards according to OSHA regulations and CDC
guidelines while performing endotracheal intubation.
KEY TERMS
anastomosis hyperextension paresis supraglottic
denudation malacia polyps vallecula
erosion Mallampati Sellick maneuver
fenestrated classification stenosis
fistula paralysis subglottic
335
2679_Ch22_335-354.indd 335 07/02/13 4:45 PM

Exercises
F 10-mL syringes F Goggles or face shields
F Adhesive removal pads F Hand sanitizer
F Airway management trainers—adult, F In-line suction catheters, various sizes
pediatric, and infant F Laryngeal mask airways (LMAs),
F Atomizer various sizes
F Basins F Laryngoscope handles
F Batteries for laryngoscopes F Magill forceps
F Bivona® Fome-Cuf® cuffed endotracheal tube F Manual resuscitators with masks, adult and
F Cloth tape infant
F Colorimetric capnometer (EasyCap™) or F Nasopharyngeal airways, various sizes
other spot-check capnography device F Oropharyngeal airways, various sizes
F Commercial endotracheal tube holders F Oxygen connecting tubing and nipple
F Cook airway exchange catheter adaptors
F Curved (MacIntosh) laryngoscope blades, F Oxygen gas source and flowmeter
adult and pediatric sizes F Replacement laryngoscope bulbs
F Endotracheal tubes: adult cuffed F Scissors
F Endotracheal tubes: Carlen’s catheter or F Silicone spray
double-lumen endotracheal tube (DLET) F Sterile and nonsterile disposable latex and
F Endotracheal tubes: Cole catheter vinyl gloves, various sizes
F Endotracheal tubes: continuous cuff suction F Sterile water or normal saline
F Endotracheal tubes: directional distal tip F Stethoscopes
(built-in stylet) F Straight (Miller) laryngoscope blades—adult,
F Endotracheal tubes: Emergency Medicine pediatric, and infant sizes
Tube (EMT®) F Stylets, adult and pediatric sizes
F Endotracheal tubes: infant uncuffed F Suction catheter kits
F Endotracheal tubes: nasal or oral Ring- F Suction source and connecting tubing
Adair-Elwyn (RAE) F Tincture of benzoin application pads
F Endotracheal tubes: pediatric size, cuffed and F Tongue blades
uncuffed
F Towels
F Endotracheal tubes: wire-reinforced (anode or
F Water-soluble lubricant
armored)
F Yankauer catheter
F Esophageal-Tracheal Combitube® (ETC)
EXERCISE 22.1 INTUBATION EQUIPMENT AND PREPARATION

EXERCISE 22 .1 .1 IDEN TIF ICATION O F I N T U B AT I O N E Q U I P ME N T
Compare the equipment provided in the laboratory with Figures 22.1 through 22.14. Identify the
items and record them on your laboratory report.
Endotracheal tube: infant uncuffed

Endotracheal tube: Carlen’s catheter or double-lumen endotracheal tube (DLET)
Endotracheal tube: Cole catheter
Curved (MacIntosh) laryngoscope blade
Endotracheal tube: wire-reinforced (anode or armored)
Endotracheal tube: adult cuffed
Endotracheal tube: Evac combined esophageal/tracheal tube
Stylet
Endotracheal tube: directional distal tip with stylet
Endotracheal tube: continuous cuff suction
Straight (Miller) laryngoscope
Airway exchange catheter
Magill forceps
Endotracheal tube: nasal or oral RAE
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C H A P T E R 22 | E N D O T R AC HEAL INTUBATION • 337
Figure 22.1. A. (Courtesy of Cook Medical

Incorporated, Bloomington, IN.)
Figure 22.2. B. (Courtesy of Teleflex

Medical, Research Triangle Park, NC.)
Figure 22.3. C. (Courtesy of Teleflex Medical, Research Triangle Park, NC.)
Figure 22.4. D. (Courtesy of Teleflex Medical, Research Triangle Park, NC.)
Figure 22.5. E. (Courtesy of Teleflex Medical, Research Triangle

Park, NC.) Figure 22.6. F.
2679_Ch22_335-354.indd 337 07/02/13 4:45 PM

Figure 22.7. G.
Figure 22.9. I.
Figure 22.8. H. (Reproduced with permission from White GC: Respiratory Notes: Respiratory
Therapists Pocket Guide. FA Davis, Philadelphia, PA, 2008, p 108.)
Figure 22.10. J.
2679_Ch22_335-354.indd 338 07/02/13 4:45 PM

Figure 22.13. M. (Courtesy of Teleflex Medical,

Research Triangle Park, NC.)
Figure 22.11. K. (Courtesy of Teleflex Medical, Research Triangle Park, NC.)
Figure 22.14. N. (Courtesy of Teleflex Medical, Research Triangle Park, NC.)
Figure 22.12. L. (Courtesy of Teleflex Medical, Research Triangle Park, NC.)
EXER C ISE 22 .1 .2 IDEN TIF I C AT I O N O F T H E C O MP O N E N T S O F A N E N D O T R A C H E A L T U B E

Select an endotracheal tube and compare it with Figure 22.15. Record the vendor or brand on
your laboratory report. Use the following list to identify the labeled parts in Figure 22.15 and
record them on your laboratory report.
15-mm connector J
Spring-loaded pilot valve C
Pilot balloon B
Cuff E
Inflation or pilot tube i
Internal diameter in millimeters A
D
Radiopaque line F
E
Murphy tip with lateral eye D
Distance markings in centimeters G
Test markings (IT or Z-79)
H
Figure 22.15. Components of an endotracheal tube. (Teleflex Medical, Research

Triangle Park, NC.)
2679_Ch22_335-354.indd 339 07/02/13 4:45 PM

EXERCISE 2 2 .1 .3 EQUIP MEN T TESTI N G

1. Gather the necessary equipment:
10-mL syringe
Basins
Batteries
Bulbs
Endotracheal tube
Laryngoscope handles and blades
Sterile water or saline solution
2. Assemble the laryngoscope as shown in Figure 22.16.
3. Open the blade and observe whether the light is lit. Record this observation on your labora-
tory report. Loosen the bulb (if not using a fiberoptic system) and observe whether the light
goes on. Record this observation on your laboratory report. Retighten the bulb.
4. Unscrew the base of the laryngoscope handle and remove the batteries. Note the size of the
batteries on your laboratory report.
5. Open the blade and observe whether the light is lit. Record this observation on your labora-
tory report.
6. Fill a basin with water or saline solution.
7. Put 5 mL of air into the 10-mL syringe and connect it to the valve on the pilot balloon.
8. Inject the air into the pilot balloon and observe the cuff inflation.
9. Submerge the cuffed end of the endotracheal tube in the basin. Observe the solution for any
air bubbles and record your observations on your laboratory report.
10. Add 5 mL more into the cuff. Squeeze the cuff gently and observe the pilot balloon. Record
this observation on your laboratory report. Place the syringe into the Luer-LokTM of the
pilot valve. Squeeze the cuff gently and observe the pilot balloon and syringe. Record this
observation on your laboratory report.
11. Remove the tube and deflate the cuff completely.
EXERCISE 2 2 .1 .4 ASSIGN MEN T OF MA LLA MPAT I C LA S S I FI C AT I O N

Frequently, the Mallampati 1. Using your laboratory partner as the “patient,” explain the purpose of this assessment.
classification is employed to 2. With your “patient” seated and his or her head placed in a neutral position, instruct the
help anticipate the difficulty “patient” to open the mouth widely and put the tongue out as far as possible. Use a tongue
of orotracheal intubation. blade if needed.
This is usually done for 3. Visually inspect the oropharynx and classify it by comparing your observations with Figure 22.17.
elective intubations but it 4. Record the Mallampati classification for your “patient” on your laboratory report.
may be of help in an
emergency intubation as
well. It is not, however, a
sole predictor of difficulty.2,3
A B C
Figure 22.16. Assembly of a laryngoscope.
2679_Ch22_335-354.indd 340 07/02/13 4:45 PM

Figure 22.17. Mallampati classification.
EXERCISE 22.2 OROTRACHEAL INTUBATION

EXER C ISE 22 .2 .1 OROTRA C H E A L I N T U B AT I O N W I T H A MA C I N T O S H B LA D E
In this exercise, two students 1. Gather the necessary equipment to intubate an adult airway management trainer using the
are to work as partners; one MacIntosh (curved) blade (make sure the trainer is properly lubricated with the silicone
will intubate and the other spray). The proper endotracheal tube and blade sizes are shown in Table 22.1.
will prepare the equipment 2. Wash or sanitize your hands and apply standard precautions and transmission-based
and assist. The student who isolation procedures as appropriate. The use of goggles or face shield is recommended in an
is to intubate should actual clinical situation.
manually resuscitate the 3. Prepare all equipment first while one student ventilates the “patient” with a manual
mannequin while the other resuscitator.
student gets all equipment 4. Open the endotracheal tube package halfway, leaving the cuffed end aseptically protected in
ready. After successful the wrapper. Insert a stylet into the tube, making sure the tip does not protrude from the
intubation, the students other end, as shown in Figure 22.18. Bend the top of the stylet (if necessary) over the top of
should switch roles. the tube to prevent it from slipping down. Shape the tube so that the curve is maintained.
Remember, in the clinical 5. Using the manual resuscitator with bag-valve mask, preoxygenate the “patient.”
sites in most cases your role 6. Suction the oropharynx.
will be as the assistant, not 7. Remove the oropharyngeal airway if one is present.
the intubator! It is imperative 8. Position the “patient’s” head in the sniffing position, as shown in Figure 22.19 by flexing
that you know how to be a the neck and tilting the head backward. Do not hyperextend. This allows alignment of the
good assistant. mouth, pharynx, and larynx. One or two towels can be used under the neck and shoulders
to help achieve this position.
9. Ensure that all equipment is functioning and readily available.
Table 22.1 Endotracheal Tubes,

Endotracheal Tubesb
Tracheostomy Tubes, and
Laryngoscope Bladesa Approximate Age or Weight Internal Diameter (ID, in mm) Outer Diameter (OD, in mm) Length (cm)
Premature infants (2–5 lb) 2.0–3.0 3.7–4.5 8
Newborn infants (5.0–5.5 lb) 3.0 4.5 9
Newborn infants to 3 mo (5.5–11 lb) 3.5–4.0 5.0–5.5 9
3–10 mo (11–18 lb) 4.3 5.7 10
10–12 mo (19–20 lb) 4.5 6.0 11
13–24 mo (20–25 lb) 5.0 6.5 12
2–3 yr (25–33 lb) 5.5 7.0 13
4–5 yr (33–44 lb) 6.0 8.0 14
6–7 yr (44–55 lb) 6.5 8.5 15
8–9 yr (55–70 lb) 7.0 9.0 16
9–10 yr (55–70 lb) 7.0 9.0 16
10–12 yr (70–85 lb) 7.5 9.5 17
12–16 yr (85–130 lb) 7.5 9.5 22.5
Adult females 8.0–9.0 10.0–12.0 19–24
Adult males 8.5–10.0 11.5–13.0 20–28
(continued)
2679_Ch22_335-354.indd 341 07/02/13 4:45 PM

Table 22.1 Endotracheal Tubes,
Tracheostomy Tubes
Tracheostomy Tubes, and
Laryngoscope Bladesa Age Jackson Tube Size OD
(continued)
Premature to newborn 00 4.5
Newborn to 3 mo 0 5.0
Up to 1 yr 1 5.5
1–3 yr 2 6.0
3–6 yr 3 7.0
6–12 yr 4 8.0
12 yr to adult 5–9 9.0–13.0
Age Laryngoscope Blades (Type and Size)
Premature Miller (0)
Infant to 3 mo Miller (1)
3–12 mo Miller or MacIntosh (11/2)
3–9 yr MacIntosh (2)
9 yr to adult MacIntosh (3)
aTube
thickness may vary with manufacturer.
bConversion
to French scale: 4 × ID or 3 × OD.
Adapted from Pilbeam, SP: Mechanical Ventilation: Physiological and Clinical Applications,
ed. 2. Mosby-Year Book, St. Louis, 1992, p. 603, with permission.
Figure 22.18. Insertion of a stylet into an

endotracheal tube.
Figure 22.19. “Sniffing” position for intubation.
2679_Ch22_335-354.indd 342 07/02/13 4:45 PM

10. Open the mouth using the crossed-finger, or scissor, technique. (See Fig. 20.5a.)
11. Holding the laryngoscope in your left hand (regardless which is your dominant hand),
insert the blade into the “patient’s” mouth, as shown in Figure 22.20.
12. Pushing aside the tongue to the left, as shown in Figure 22.21, advance the blade until the
epiglottis is visualized, as shown in Figure 22.22. Use the following list to identify the
anatomic landmarks and record them on your laboratory report.
Glottis
Aryepiglottic fold
Epiglottis
Arytenoid cartilage
Median glossoepiglottic fold
13. Continue to advance the tip of the blade into the vallecula, as shown in Figure 22.23, and
indirectly expose the glottis by applying an upward and forward lift with your wrist kept
straight, as shown in Figure 22.24. Do not use the blade as a lever by resting it on the
upper teeth. This prying motion will result in cracked or broken teeth. The Sellick
maneuver (the application of pressure on the cricoid cartilage by an assistant) is sometimes
beneficial in visualization, as shown in Figure 22.25. The glottis is now exposed.
Figure 22.20. Insertion of Figure 22.21. Displacement of the

laryngoscope blade into the mouth. tongue.
A B
C
E
Figure 22.22. Visualization of the landmarks for intubation.
2679_Ch22_335-354.indd 343 07/02/13 4:45 PM

Figure 22.24. The upward, forward tilt to expose the glottis. Notice
that the blade is not resting on the teeth.
Figure 22.23. Tip of the Macintosh blade in the vallecula.
Figure 22.25. Applying cricoid pressure.
14. No intubation attempt should last longer than 30 seconds. If problems are encountered
with the visualization procedure, stop the intubation attempt and reoxygenate the patient
with 100% oxygen between attempts for at least 1 minute.
15. Have your assistant remove the tube from the wrapper without contaminating the cuffed
end. Without taking your eyes off the glottis, insert the endotracheal tube into the right side
of the mouth, advancing it until the cuff goes just beyond the vocal cords.
16. Holding the tube securely in position, quickly but gently remove the laryngoscope blade
from the mouth. The assistant will help remove the stylet and inflate the cuff with 5 to
10 mL of air.
17. Ventilate and oxygenate the “patient.” Observe for bilateral symmetrical chest expansion.
18. Have your assistant place an end-tidal colorimetric capnometer (e.g., EasyCap™) between
the 15-mm adapter endotracheal and the resuscitator bag connection.
19. Auscultate for bilateral breath sounds.
20. Auscultate the epigastric region to listen for air in the stomach.
21. If no breath sounds are heard, deflate the cuff, remove the tube, and ventilate with a bag-
valve mask until the procedure is attempted again.
22. If unilateral sounds are heard, deflate the cuff and withdraw the tube gently while
continuing to bag the “patient” until bilateral sounds are heard. Then reinflate the cuff.
23. Secure the tube with tape or with a commercial orotracheal tube holder. See Exercise 22.3.
24. Attach the “patient” to an oxygenation or ventilation device.
25. Remove your gloves and other personal protective equipment.
26. Wash your hands and dispose of waste.
2679_Ch22_335-354.indd 344 07/02/13 4:45 PM

EXER C ISE 22 .2 .2 OROTRA C H E A L I N T U B AT I O N W I T H A MI LLE R B LA D E

1. Replace the MacIntosh blade used in the previous exercise with a Miller blade.
2. Repeat all of the steps in the previous exercise.
3. Directly expose the glottis by picking up the epiglottis with the tip of the blade, as shown in
Figure 22.26.
4. Continue the remaining steps in the previous exercise.
EXER C ISE 22 .2 .3 IN TUBAT I O N W H E N A N E S O P H A G E A L-T R A C H E A L C O MB I T U B E ® ( E T C )

AIR WAY I S I N P LA C E
1. Select an airway management trainer that has an ETC tube airway in place.
2. Intubate the trainer as previously described, moving the ETC out of the way without
removing it.
3. Once the endotracheal tube (ETT) is in place, deflate the ETC cuffs.
4. Remove the ETC once the ETT is in place.
5. Attach the oxygenation or ventilation device to the 15-mm ETT adapter.
EXER C ISE 22 .2 .4 IN TUBAT I O N W H E N A LA R Y N G E A L MA S K A I R WAY ( LMA ) I S I N P L A C E

1. Select an airway management trainer that has an LMA tube airway in place.
2. Intubate the trainer by inserting the ETT through the LMA.
3. Deflate the LMA cuff.
4. Remove the LMA once the ETT is in place.
5. Attach the oxygenation or ventilation device to the 15-mm ETT adapter.
EXER C ISE 22 .2 .5 N ASOTRA C H E A L I N T U B AT I O N

1. Gather the necessary equipment.
2. Lubricate the nose of the adult airway management trainer with silicon spray. In the clinical
setting, a water-soluble jelly is used to lubricate the nasotracheal tube.
3. Wash or sanitize hands and apply standard precautions and transmission-based isolation
4. Prepare the “patient” as in Exercise 22.2.1.
5. Insert the tube into one of the nares.
6. Advance the tube into the oropharynx. Never force a tube. If an obstruction is met, attempt
to pass the tube through the other naris.
7. When the tube is in the oropharynx, insert the laryngoscope blade into the mouth as
previously described and expose the glottis.
8. Using the Magill forceps, pick up the tip of the nasotracheal tube behind the cuff.
Figure 22.26. Exposure of the glottis using the Miller blade.
2679_Ch22_335-354.indd 345 07/02/13 4:45 PM

9. Ask your laboratory partner to push on the tube as you direct the tip into the glottis. Steps
8 and 9 are shown in Figure 22.27.
10. Once the tube is in the trachea, gently remove the equipment from the mouth and continue
as in the previous exercises.
Blind nasotracheal intubation is sometimes attempted. It is difficult to practice in the laboratory
setting because the passing of the tube requires a spontaneously breathing subject.4 The procedure
is basically the same for nasotracheal intubation except that a laryngoscope and forceps are not
used. The RCP must time the insertion of the tube with the opening of the epiglottis. Successful
attempts are often indicated by an emission of a harsh sound as the tube passes the vocal cords,
the patient’s inability to speak, and the feel of moist air coming from the tube on exhalation.
EXERCISE 2 2 .2 .6 IN FAN T IN TUBATIO N

1. Gather the necessary equipment. Refer to Table 22.1 for the proper size tubes and blades.
2. Select an infant airway management trainer and lubricate the pharynx with silicone spray. (In
a clinical setting, tubes would not be lubricated.)
3. Preoxygenate the “patient.”
4. Position the head in the neutral, or “sniffing,” position.
5. Intubate the trainer using the techniques learned in Exercise 22.2.1.
6. Continue the steps as described in Exercise 22.2.1.
Figure 22.27. Nasal intubation using Magill forceps.
2679_Ch22_335-354.indd 346 07/02/13 4:45 PM

EXERCISE 22.3 SECURING AN ENDOTRACHEAL TUBE
For this exercise, use the 1. Have you and your laboratory partner wash or sanitize his or her hands, apply standard
intubated mannequins from precautions and transmission-based isolation procedures as appropriate, and hold the
the previous exercises. endotracheal tube securely in position while you perform the following steps. Note the
position of the endotracheal tube. You may be using cloth tape or a commercial endotracheal
tube holder.
2. Do not apply gloves until the tape is prepared. Prepare the cloth tape for use to secure the
endotracheal tube.
3. Put on your gloves.
4. The following should NOT be done to the mannequin or patient simulator! If you are using
your partner as the “patient,” you can enhance the adhesiveness of the tape by applying
tincture of benzoin to the “patient’s” skin using a 4×4 gauze pad or commercial prep pads.
Do not spray or apply the liquid directly to the “patient’s” face.
5. Apply the tape using the methods shown in Figure 22.28 and Figure 22.29, or use the
commercial holder as shown in Figure 22.30. Ensure that the tube position is correct. Secure
the tape around the oropharyngeal airway to serve as a bite block. Reassess correct tube
placement when finished.
“Chart” the procedure on your laboratory report.
6. Repeat the exercise using a nasotracheally intubated mannequin.
7. Repeat the exercise using an infant mannequin.
Figure 22.28. Securing the endotracheal tube with tape.
2679_Ch22_335-354.indd 347 07/02/13 4:45 PM

Figure 22.29. Securing the tube in a bearded

patient. First attach a strip of tape sticky side down
to the main piece.
A B
Figure 22.30. Securing an endotracheal tube using a commercial endotracheal tube holder. (Courtesy of Cardinal Health, Dublin, OH.)
RE F E RE N CE S
1. American Association for Respiratory Care: AARC clinical practice guideline: Management of airway emergencies. Respir Care 40:
749–760, 1995.
2. Sofair, E: Preanesthetic assessment: The professional singer with a difficult airway. Anesthesiology News 1:40, 1993.
3. Whitten, CE: Anyone Can Intubate. KW Publications, San Diego, 1996, p. 41.
4. Finucane, BT, and Santora, AH: Principles of Airway Management, ed. 2 Mosby, St. Louis, 1996.
2679_Ch22_335-354.indd 348 07/02/13 4:45 PM

Laboratory Report
CHAPTER 22: ENDOTRACHEAL INTUBATION
Name: Date:
Data Collection
EXERCISE 22.1 Intubation Equipment and Preparation
E X E R C IS E 22 . 1. 1 ID E NT IFIC ATION OF IN TUBATION EQUIPMEN T
A. _________________________________________________________________________________________________________
B. _________________________________________________________________________________________________________
C. _________________________________________________________________________________________________________
D. _________________________________________________________________________________________________________
E. _________________________________________________________________________________________________________
F. _________________________________________________________________________________________________________
G. _________________________________________________________________________________________________________
H. _________________________________________________________________________________________________________
I. _________________________________________________________________________________________________________
J. _________________________________________________________________________________________________________
K. _________________________________________________________________________________________________________
L. _________________________________________________________________________________________________________
M. _________________________________________________________________________________________________________
N. _________________________________________________________________________________________________________
E X E R C IS E 22 . 1. 2 ID E NT IFIC ATION OF THE COMPON EN TS OF AN EN DOTRACHEAL TUBE
Vendor or brand: ______________________________________________________________________________________________
A. _________________________________________________________________________________________________________
B. _________________________________________________________________________________________________________
C. _________________________________________________________________________________________________________
D. _________________________________________________________________________________________________________
E. _________________________________________________________________________________________________________
F. _________________________________________________________________________________________________________
G. _________________________________________________________________________________________________________
H. _________________________________________________________________________________________________________
I. _________________________________________________________________________________________________________
J. _________________________________________________________________________________________________________
2679_Ch22_335-354.indd 349 07/02/13 4:45 PM

E XE RCI SE 2 2 .1 . 3 E Q U IP M E N T T E S T ING
Light observation: _____________________________________________________________________________________________
Light observation with loosened bulb: _____________________________________________________________________________
If the lamp failed to light, list the items you would check in the order in which you would check them: __________________________
____________________________________________________________________________________________________________
Size of batteries: ______________________________________________________________________________________________
Light observation with blade open: _______________________________________________________________________________
Observations of endotracheal tube cuff testing in solution: _____________________________________________________________
Observations of cuff and pilot balloon: _____________________________________________________________________________
Observations of the cuff and pilot balloon with syringe in place: ________________________________________________________
____________________________________________________________________________________________________________
E XE RCI SE 2 2 .1 . 4 A S S IG N M E N T O F MA L L A MPATI CL ASSIF ICATION
Mallampati classification: ______________________________________________________________________________________
EXERCISE 22.2 Orotracheal Intubation
E XE RCI SE 2 2 .2 . 1 O R O T R A C H E A L IN T U B AT ION W ITH A MACIN TOSH BL ADE
Identify the anatomic landmarks:
A. _________________________________________________________________________________________________________
B. _________________________________________________________________________________________________________
C. _________________________________________________________________________________________________________
D. _________________________________________________________________________________________________________
E. _________________________________________________________________________________________________________
EXERCISE 22.3 Securing an Endotracheal Tube
Chart the intubation procedure, your assessment of tube placement, and the securing of the endotracheal tube: __________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
2679_Ch22_335-354.indd 350 07/02/13 4:45 PM


1. You have been asked by the nursing supervisor to supply an adult intubation tray for the emergency department. List
all the equipment that you would recommend.
2. When would a topical anesthetic be indicated during the intubation procedure? What anesthetics can be used?
3. In a restless, fighting patient requiring immediate oral intubation, what pharmacological agent(s) could be used to facil-
itate intubation?
4. Describe in specific radiologic terms the proper location of an endotracheal tube.
-Through mouth then through vocal cords so that the distal tip lies between vocal cords and carina, 3-5
cm above the carina
-Around the 3rd intercostal space
-look around the aortic knob
5. The emergency medical technicians have brought in a 65-year-old patient in cardiac arrest. The patient had been venti-
lated with a manual resuscitator and mask. As you attempt to ventilate, the patient vomits.
A. What would be your immediate actions?

remove the mask, turn the pt on their side, suction the vomit to clear up all the vomit to prevent
aspiration, use a finger sweep(use caution) then resume
B. During your next attempt to intubate, you observe a large piece of undigested steak blocking your view of the
glottis. How would you clear the airway, and what equipment would be needed?
use magill forceps(bending tweezers in hospital)
attempt finger sweep(use caution)
C. After the airway is cleared, you attempt to intubate the patient. However, your ability to intubate is impeded by
the movement of the chest compressions. What would you suggest?
Possibly an LMA
possibly an Endotracheal tube, ask them to pause right when u are ready to insert the tube
2679_Ch22_335-354.indd 351 07/02/13 4:45 PM

6. A 19-year-old male weighing 150 lb has been brought to the emergency department by ambulance after being struck by
a motor vehicle while on his motorcycle. The patient was found unconscious, with multiple visible fractures on the
face. The paramedics placed an immobilization collar and inserted an LMA. The physician recommends that the pa-
tient be orally intubated prior to being taken for a CT scan.
A. What endotracheal tube size and depth of insertion would you recommend for this patient?
22-25cm depth, always confirmm placement intubate pt without moving the pt like using
8-8.5 size equipment called a bougie, or video laryngoscopy
B. While assembling and checking the intubation equipment, you notice that the light on the laryngoscope blade
flickers on and off. What should be done to remedy this situation?
get a different blade, change battery etc
C. Upon intubation, blood continues to form in the patient’s oropharynx despite repeated attempts to suction. What
clue may help you to locate the larynx while the view is obstructed by blood?
use a bougie stylet, bronchoscopy to do a suction while it is in there
D. Once the patient is intubated, what is the single most effective way to confirm that the position of the endotra-
cheal tube is in the trachea?
End tidal CO2 capnography-is most effective in determining this
7. A physician asks you to assist in intubating a morbidly obese 46-year-old female patient.
A. When choosing between the Miller and the MacIntosh laryngoscope blades, which would be the best
choice? Why?
B. Are there any other considerations when intubating a morbidly obese patient?
2679_Ch22_335-354.indd 352 07/02/13 4:45 PM


STUDENT: DATE:
ORAL ENDOTRACHEAL INTUBATION
PERFORMANCE LEVEL
PERFORMANCE RATING
Performance Level:
NA = Not applicable
Performance Rating:


3. Hyperoxygenates/hyperventilates the patient with 100% BVM and oral airway
4. Performs, or has assistant perform, the following:
A. Selects appropriate laryngoscope blade and ETT size
B. Tests function of lamp
C. Checks function of cuff; lubricates tube with water-soluble lubricant
D. Inserts stylet into tube; ensures it is not protruding from end or lateral eye
5. Inserts and manipulates blade appropriately; suctions if needed
6. Inserts ETT under direct visualization within 15 seconds
7. Immediately ventilates following insertion
8. Inflates cuff with maximum of 10 cc air
9. Stabilizes ETT until secured with tape/ETT stabilizer
10. Verifies ETT position by chest rise, auscultation, and capnometry
11. Correctly secures ETT with tape or commercial tube stabilizer
FOLLOW-UP
12. Measures cuff volume, pressure
13. Confirms tube position on CXR
2679_Ch22_335-354.indd 353 07/02/13 4:45 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch22_335-354.indd 354 07/02/13 4:45 PM

CHAPTER Tracheostomy Care
INTRODUCTION For long-term artificial airway availability, the tracheostomy tube is the airway of
choice. Maintenance of the tracheostomy tube is essential and is the responsibility of
the respiratory care practitioner (RCP). These responsibilities include securing the
tube, adequate humidification and secretion clearance, providing cuff and stoma care,
troubleshooting airway-related problems and changing tracheostomy tubes. In addition,
the RCP may be asked to assist with clinical decisions such as assessing the potential for
speech, determining the type and style of tracheostomy tube, and developing care plans
to avoid long-term complications.1 Although an RCP is not responsible for the actual
tracheotomy procedure, the RCP may be called on to assist with the procedure, replace
a displaced tracheostomy tube, or change it from one type of tube to another. Detailed
knowledge of these tubes is also an essential part of the responsibility of the RCP.
OBJECTIVES 1. Practice communication skills needed for assessing the level of patient comprehension while
Upon completion of this instructing patients in airway care procedures.
chapter, you will be able to: 2. Practice medical charting for airway care procedures.
4. Secure a tracheostomy tube by changing twill tape and commercial tracheostomy tube holders.
5. Identify the various types of tracheostomy tubes, buttons, and adjuncts and their component
parts.
6. Perform tracheostomy care, including equipment cleaning and stoma care.
7. Change a tracheostomy tube on an adult airway management trainer.
8. Provide for adequate patient communication with an artificial airway in place.
KEY TERMS
decannulation dysphonia stoma tracheotomy
dysphagia obturator tracheostomy
355
2679_Ch23_355-368.indd 355 07/02/13 4:45 PM

Exercises
F 4×4 sterile gauze F Pulse oximeter
F 10-mL syringes F Scissors
F Airway management trainer F Shiley speaking valve with oxygen port
F Basins F Silicone spray
F Bivona® or Kamen-Wilkinson Fome-Cuf® F Sterile and nonsterile disposable latex and
tubes vinyl gloves, various sizes
F Briggs adaptors (T-piece) F Sterile water or normal saline
F Cloth tape F Stethoscopes
F Cotton swabs F Suction catheter kits
F Disposable and nondisposable inner cannulas F Suction machines
F Fenestrated and nonfenestrated cannulas F Towels
F Goggles or face shields F Tracheal buttons
F Hydrogen peroxide F Tracheostomy care kits
F Lanz-McGinnis cuff tubes F Tracheostomy collars
F Large-volume nebulizer F Tracheostomy communication devices
F Large-bore corrugated tubing F Tracheostomy tube holders
F Letter board or pad and pen/pencil F Tracheostomy tubes, various sizes and styles:
F Manual resuscitators with masks—adult and F Jackson metal
infant F Cuffed and cuffless
F Montgomery tubes F Cuffed and cuffless fenestrated
F Oxygen connecting tubing and nipple adaptors F Twill tape
F Oxygen gas source and flowmeter F Water-soluble lubricant
F Passy-Muir, Shiley, or other brand of speak- F Yankauer catheter
ing valves
EXERCISE 23.1 TRACHEOSTOMY TUBES

EXERCISE 23.1.1 COMPON EN TS OF T R A C H E O S T O MY T U B E S
1. Compare the various components of the tracheostomy tube provided in the laboratory and
compare it with Figure 23.1. Identify the components and record them on your laboratory
report.
Disposable inner cannula
Nondisposable inner cannula
Outer cannula
Pilot balloon
Pilot valve
Cuff
Fenestration
Cannula cap
Obturator
15-mm connector
Neck plate
Inflation line
2. Open a tracheostomy tube box and examine the contents and the manner in which they are
packed. Pay close attention to what is sterile and what is not. Record the contents of the
box on your laboratory report. Include the manufacturer, size, and style of the tube.
2679_Ch23_355-368.indd 356 07/02/13 4:45 PM

C H A P T E R 23 | T R AC HEOS TOM Y C AR E • 357
Figure 23.1. Components of tracheostomy tubes.

(Adapted from Shiley Tracheostomy Products,
courtesy of Mallinckrodt Medical, St. Louis, MO,
with permission.)
EXER C ISE 23 .1 .2 TYP ES O F T R A C H E O S T O MY T U B E S A N D D E V I C E S

Compare the various types of tracheostomy tubes and devices provided in the laboratory and
compare them with Figure 23.2, A through G. Identify the type of tube or device and record it on
Montgomery tube
Tracheostomy button
Lanz-McGinnis cuff
Self-inflating foam cuff
Bias-closed speaking valve
Pitt speaking tube
Jackson tracheostomy tube
2679_Ch23_355-368.indd 357 07/02/13 4:45 PM

D
Figure 23.2. Tracheostomy tubes and devices. ([A] Courtesy of Olympic Medical, Seattle, WA. [C] Courtesy of Bivona Medical
Technologies, Gary, IN with permission.
2679_Ch23_355-368.indd 358 07/02/13 4:45 PM

G
Figure 23.2.—cont’d [E] Courtesy of Passy-Muir Inc., Irvine, CA. [F] Courtesy of Boston Medical Products, Westborough, MA.)
2679_Ch23_355-368.indd 359 07/02/13 4:45 PM

EXERCISE 23.2 TRACHEOSTOMY TUBE CARE

EXERCISE 2 3.2.1 TR ACHEOS TOMY C A R E A N D C LE A N I N G
NOTE: Tracheostomy patients 1. Wash your hands and apply standard precautions and transmission-based isolation
should always have a procedures as appropriate.
replacement tracheostomy 2. Gather the necessary equipment:
tube at the bedside in case Tracheostomy care kit
an emergency replacement Suction kit
becomes necessary. Gloves
Peroxide
Sterile water or saline
Spare inner cannula or disposable cannula
3. Explain the procedure and verify that your patient understands.
4. Suction thoroughly.
5. Remove the old dressing and discard in an infectious waste container.
6. Remove the inner cannula and replace with the spare red-top cannula if a nondisposable
cannula is in place.
7. Open the tracheostomy care kit and fill one basin with hydrogen peroxide and the other
with sterile saline.
8. Scrub the cannula with a brush in the peroxide and rinse with the sterile saline.
9. Replace the permanent cannula.
10. If a disposable cannula is used, remove the dirty cannula, dispose of it properly, and replace
it with a clean disposable cannula.
11. Clean the stoma site and exterior portions of the tube using peroxide, cotton-tipped
applicators, and a pipe cleaner for the tube crevices.
12. Replace the dressing using a precut 4×4 gauze pad.
13. Remove the old ties by cutting them with scissors. Be careful not to cut the pilot tube.
Commercial tracheostomy tube holders can be removed and replaced by following the
manufacturer’s instructions.
14. Attach the tracheostomy twill tape to one end of the tube by making a loop and inserting it
into one of the holes on the neck plate. Bring the other end back through the loop and pull.
Bring the tape around the patient’s neck and insert one end of the tape into the other hole.
Tie the tube in place by making a square knot on the side of the neck. Avoid overtightening
by placing one finger between the tape and the patient’s neck (Fig. 23.3).
15. Ensure that the tube is in the proper position, and reassess the patient.
16. Ensure that all equipment is disposed of in the proper waste container.
17. Remove gloves and wash your hands.
Figure 23.3. Retying tracheostomy tapes. (Courtesy of Shiley

Tracheostomy Products, Mallinckrodt Medical, St. Louis, MO.)
2679_Ch23_355-368.indd 360 07/02/13 4:45 PM

EXER C ISE 23 .2 .2 TRAC HEO S T O MY T U B E I N S E R T I O N

1. Select a tracheostomized adult airway management trainer.
Tracheostomy tube and components
Tracheostomy ties or holder
Suction equipment
Water-soluble lubricant (silicone spray)
Basin
Sterile gloves
3. Using your laboratory partner as the patient, explain the procedure for changing the
tracheostomy tube.
4. Suction the trachea based on “patient” assessment.
5. Wash your hands, put on sterile gloves, and use other standard precautions and
6. Your laboratory partner will now serve as your assistant. Have your partner open the new
tracheostomy tube box, remove the tube, and place it on a sterile field.
7. Have your partner fill a basin with sterile solution.
8. While you hold the new tube in your sterile hand, instruct your partner to inject 5 mL of
air into the cuff. Remember that your partner cannot touch the tube.
9. Check the tube for cuff leaks.
10. If no leaks are present, deflate the cuff completely.
11. Have your partner attach the new, clean tracheostomy ties or holder.
12. Remove the inner cannula and insert the obturator.
13. Lubricate the tip of the tracheostomy tube/obturator.
14. Reassure your “patient” and position the “patient’s” head. The “patient” should be seated
in a semi-Fowler’s position with the neck slightly extended.
15. Have your partner loosen or untie the old tracheostomy ties and deflate the cuff if it is
inflated.
16. Remove the oxygen or humidity therapy device and place aseptically.
17. With one hand, remove the old tracheostomy tube.
18. Visually inspect the stoma for bleeding or infection.
19. Insert the new tube as shown in Figure 23.4. Gently introduce the tip of the obturator into
the stoma and advance the tube into the trachea with a slightly downward motion. Do not
force if resistance is met.
20. Quickly remove the obturator and insert the inner cannula. Make sure that one finger keeps
the tracheostomy tube in place until it is secured.
21. Inflate the cuff if ordered.
22. Ensure proper placement by auscultation, feeling airflow through the tube and chest
expansion.
23. Tie the tube into place. Remember to place one finger under the tie to prevent
overtightening. Velcro tube holders may also be employed.
24. Restore the “patient” to the previous oxygen or humidity therapy device.
25. Dispose of the dirty tube, ties, and gloves in the proper receptacle.
26. Wash your hands.
Figure 23.4. Insertion of a replacement tracheostomy

tube. (Adapted from Shiley Tracheostomy Products,
Mallinckrodt Medical, St. Louis, MO with permission).
2679_Ch23_355-368.indd 361 07/02/13 4:45 PM

EXERCISE 2 3 .2 .3 TRAC HEOSTOMY TU B E D E C A N N U LAT I O N

1. Select a tracheostomized adult airway management trainer.
4×4 sterile gauze dressings
Cloth tape
Suction equipment
Gloves
3. Using your laboratory partner as the patient, explain the procedure for removing the
tracheostomy tube.
4. Suction the trachea based on “patient” assessment.
5. Wash your hands, put on sterile gloves, and use other standard precautions and
6. If the tube is cuffed, ensure that the cuff is deflated. If the cuff is inflated, deflate it
completely.
7. Undo the tracheostomy tube holder or untie the twill tape.
8. Remove the tracheostomy tube.
9. Clean the stoma with sterile gauze damp with sterile water or normal saline.
10. Dry the area thoroughly.
11. Fold sterile gauze in quarters and place it over the stoma.
12. Tape the gauze over the stoma.
13. Instruct the “patient” that it is important to support the gauze by putting several fingers
and applying slight pressure when speaking and coughing.
14. Observe the “patient” supporting the dressing during speaking and coughing to confirm the
“patient’s” understanding. Reinstruct the “patient” if necessary.
15. Dispose of all waste in the appropriate canister.
RE F E RE N CE
1. Pierson, DJ: Tracheostomy from A to Z: Historical context and current challenges. Respir Care 50:473–475, 2005.
2679_Ch23_355-368.indd 362 07/02/13 4:45 PM

Laboratory Report
CHAPTER 23: TRACHEOSTOMY CARE
Name: Date:
Data Collection
EXERCISE 23.1 Tracheostomy Tubes
E X E R C IS E 23 . 1. 1 C O MP O N E N T S OF TRACHEOSTOMY TUBES
A. ___________________________________________________________________________________________________________
B. ___________________________________________________________________________________________________________
C. ___________________________________________________________________________________________________________
D. ___________________________________________________________________________________________________________
E. ___________________________________________________________________________________________________________
F. ___________________________________________________________________________________________________________
G. ___________________________________________________________________________________________________________
H. ___________________________________________________________________________________________________________
I. ___________________________________________________________________________________________________________
J. ___________________________________________________________________________________________________________
K. ___________________________________________________________________________________________________________
L. ___________________________________________________________________________________________________________
Manufacturer: _________________________________________________________________________________________________
Size of tube: __________________________________________________________________________________________________
Type of tube: __________________________________________________________________________________________________
Box contents: _________________________________________________________________________________________________
_____________________________________________________________________________________________________________
E X E R C IS E 23 . 1. 2 ID E NT IFIC ATION OF TRACHEOSTOMY TUBES AN D DEVICES
A. ___________________________________________________________________________________________________________
B. ___________________________________________________________________________________________________________
C. ___________________________________________________________________________________________________________
D. ___________________________________________________________________________________________________________
E. ___________________________________________________________________________________________________________
F. ___________________________________________________________________________________________________________
G. ___________________________________________________________________________________________________________
2679_Ch23_355-368.indd 363 07/02/13 4:45 PM


1. You are changing a tracheostomy tube in a mechanically ventilated patient with no spontaneous respirations. You
cannot get the new tube in. Describe in detail what you would do.
2. Al Strachen is a 16-year-old patient with quadriplegia and a C7 fracture caused by a diving accident. He is currently in
a rehabilitation facility. He has a size 6 nonfenestrated cuffed tracheostomy tube in place. The physiatrist has requested
that the nurse provide a tracheostomy adjunct to allow the patient to speak. The nurse obtained a Passy-Muir valve
and attached it to the 15-mm adapter of the inner cannula. You were then called STAT to evaluate the patient for
severe respiratory distress. Explain why the patient did not tolerate the procedure and what you would need to do
to correct the situation.
3. In what clinical situations would the following tracheostomy tubes be recommended?
A. Cuffed tracheostomy tube
B. Uncuffed tracheostomy tube
C. Fenestrated tracheostomy tube
4. What are some of the clinical signs and symptoms that might suggest a tracheostomy tube is occluded? What actions
should you take based on the findings?
2679_Ch23_355-368.indd 364 07/02/13 4:45 PM


STUDENT: DATE:
TRACHEOSTOMY CARE
PERFORMANCE LEVEL
PERFORMANCE RATING
Performance Level:
NA = Not applicable
Performance Rating:


3. Verifies the size and type of airway
4. Opens and prepares the tracheostomy care kit; fills basins with hydrogen peroxide and sterile normal saline; applies a sterile drape
5. Suctions the trachea
6. Removes and discards old tracheostomy dressing
7. Removes the inner cannula and replaces with a spare cannula if available; discards if cannula is disposable
8. Scrubs the inner cannula with peroxide; rinses with saline if a nondisposable cannula is being used
9. Replaces the inner cannula; if disposable, replaces inner cannula with new one
10. Cleans the stoma site and exterior portions of the tube using peroxide, sterile cotton-tipped applicators, and pipe cleaners
11. Replaces the dressing with a sterile precut 4×4 gauze
12. Removes the old ties or commercial tube holder and replaces with clean ones
13. Ensures that the tube is secured in the proper position; verifies airway patency, ventilation, and oxygenation
FOLLOW-UP
2679_Ch23_355-368.indd 365 07/02/13 4:45 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch23_355-368.indd 366 07/02/13 4:45 PM


STUDENT: DATE:
TRACHEOSTOMY TUBE CHANGE
PERFORMANCE LEVEL
PERFORMANCE RATING
Performance Level:
NA = Not applicable
Performance Rating:

2. Sedates the patient if needed; allows adequate time for sedation to take effect

4. Suctions the patient’s trachea
5. Performs stoma care; visually inspects for bleeding, erosion, or signs of infection
6. Positions the patient in semi-Fowler’s position with the head slightly extended
7. Opens a new tracheostomy tube box; places the tube on sterile field
8. Checks the cuff for leaks if applicable; deflates the cuff
9. Attaches new ties or commercial tube holder
10. Lubricates the tip of obturator with a sterile, water-soluble lubricant
11. Removes the inner cannula and inserts the obturator into a new tube
12. Loosens or unties the old tracheostomy ties and deflates the cuff if applicable
13. Removes the oxygen or humidity device
14. Removes the old tracheostomy tube
15. Inserts a new tube
16. Removes the obturator and inserts the inner cannula; inflates the cuff, if necessary
17. Ensures correct tube placement; verifies patent airway; assesses the patient’s ventilation and oxygenation
18. Reapplies the oxygen or humidity device
19. Secures the tube in place
20. Replaces the soiled tracheostomy dressing with a sterile, precut dressing if needed
FOLLOW-UP
22. Ensures that a spare tracheostomy tube of the same size and type is available at the patient’s bedside
23. Soaks the old tracheostomy tube in peroxide for 20 minutes
24. Uses pipe cleaners and brushes to remove organic debris from the inner and outer cannula
25. Soaks the tracheostomy tube in soapy water
26. Rinses, disinfects, or sterilizes the tracheostomy tube according to department policy
2679_Ch23_355-368.indd 367 07/02/13 4:45 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch23_355-368.indd 368 07/02/13 4:45 PM

CHAPTER Artificial Airway
Care and
Maintenance
INTRODUCTION Once an artificial tracheal airway is in place, meticulous maintenance and care are
needed to prevent infection, airway emergencies, and other complications of prolonged
intubation.
The respiratory care practitioner (RCP) qualified to intubate may also extubate patients. The
RCP must assess the patient after extubation for laryngeal edema and vocal cord injury.
The RCP must provide appropriate oxygenation and humidification. Administration of
racemic epinephrine or steroids may help relieve airway obstruction caused by edema.
Lack of appropriate airway care can lead to short- and long-term complications ranging
from minor bleeding or edema to permanent anatomical airway changes or life-threatening
emergencies.1 Airway emergencies include inadvertent extubation, cuff leak, and
obstructed airway with failure to provide adequate ventilation. Injuries associated with
airway placement include tissue pressure necrosis, granulomas, tracheoesophageal or
arterial fistula, tracheomalacia, tracheal stenosis, laryngotracheal web formation, vocal
cord paralysis, and paresis.
OBJECTIVES 1. Practice communication skills needed for assessing the level of patient comprehension while
Upon completion of this instructing patients in airway care procedures.
chapter, you will be able to: 2. Practice medical charting for airway care procedures.
4. Resecure an endotracheal tube in place by changing cloth tape and commercial endotracheal
tube holders.
5. Reposition an endotracheal tube and assess the proper size and placement.
6. Perform minimum occluding volume (MOV) and minimal leak technique (MLT) cuff
inflation procedures.
7. Measure airway cuff pressures with aneroid and mercury pressure manometers.
8. Extubate a patient and evaluate the patient’s respiratory status after extubation.
9. Provide appropriate postextubation airway care, including oxygenation, humidification, and
pharmacological treatment.
10. Identify airway emergencies and take appropriate actions to ensure patient ventilation and
oxygenation, as well as troubleshoot equipment, including cuff leaks, tube obstructions, tube
malpositions, and inadvertent extubation.
11. Identify the various types of tracheostomy tubes, buttons, and adjuncts and their component
parts.
12. Perform tracheostomy care, including equipment cleaning and stoma care.
13. Change a tracheostomy tube on an adult airway management trainer.
14. Provide for adequate patient communication with an artificial airway in place.
369
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KEY TERMS
extubation granuloma tracheomalacia
Exercises
F 10-mL syringes F Needles, various sizes
F 4×4 sterile gauze F Oropharyngeal airways, various sizes
F Aerosol masks F Oxygen connecting tubing and nipple
F Airway management trainers adaptors
F Basins F Oxygen gas source and flowmeter
F Batteries for laryngoscopes F Posey Cufflator™ cuff inflation device
F Briggs adaptors (T-piece) F Pressure manometers
F Cloth tape F Pulse oximeter
F Colorimetric capnometry (Easy Cap™) or F Replacement laryngoscope bulbs
other spot-check capnography device F Scissors
F Cotton swabs F Silicone spray
F Endotracheal tube holders F Sterile and nonsterile disposable latex and
F Endotracheal tubes, various sizes vinyl gloves, various sizes
F Endotracheal tubes obstructed by Silly F Sterile water or normal saline
Putty®, Play-Doh®, or material of similar F Stethoscopes
consistency F Stylets
F Endotracheal tubes with ruptured cuff, F Suction catheter kits
malfunctioning pilot balloon, cut pilot tube F Suction machines
F Goggles or face shields F Swivel adapter and deadspace tubing
F Hemostats F Three-way stopcocks
F Large-bore corrugated tubing F Tincture of benzoin
F Large-volume nebulizer F Toothbrush and toothpaste
F Laryngoscope blades and handles: F Towels
F Miller (various sizes) F Tracheostomy collars
F MacIntosh (various sizes) F Water-soluble lubricant
F Lemon glycerin swabs F Yankauer catheter
F Letter board or pad and pen/pencil
F Manual resuscitators with masks, adult and
infant
EXERCISE 24.1 CUFF CARE

EXERCISE 2 4 .1 .1 MIN IMAL LEAK TE C H N I Q U E ( MLT )
1. Orally intubate an airway management trainer.
2. Verify correct tube placement as practiced in Chapter 22. Record the endotracheal tube size
and centimeter mark to the mouth on your laboratory report.
3. While your laboratory partner is manually ventilating the mannequin, use a 10-mL syringe to
slowly inject air into the pilot balloon of the endotracheal tube.
4. Continue to inflate the cuff until no leak is heard while auscultating the lateral neck (this will
have to be simulated on the mannequin). Withdraw a slight amount of air from the cuff until
a small leak is heard above the cuff on the lateral neck during peak inspiration. If air leakage
is felt from the nose or mouth, too large a leak has been created.
5. Note the total volume of air used to inflate the cuff, and record the volume on your
laboratory report.
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C H A P T E R 24 | A R T I FI C I A L A I R WAY C A R E AND M AINTENANC E • 371
EXER C ISE 24 .1 .2 MIN IMU M O C C LU D I N G V O LU ME ( MO V )

1. Orally intubate an airway management trainer.
2. Verify correct tube placement as practiced in Chapter 22. Record the endotracheal tube size
and centimeter mark to the mouth on your laboratory report.
3. While your laboratory partner is manually ventilating the mannequin, use a 10-mL syringe to
slowly inject air into the pilot balloon of the endotracheal tube.
4. Continue to inflate the cuff until no leak is heard while auscultating the lateral neck (this will
have to be simulated on the mannequin). Maximum inflation should be done during peak
inspiration of positive pressure breath where the seal is needed most.
5. Note the total volume of air used to inflate the cuff, and record the volume on your
laboratory report.
EXER C ISE 24 .1 .3 C UF F PRE S S U R E ME A S U R E ME N T

1. Inflate the cuff of an orally intubated mannequin to MOV.
2. Obtain a three-way stopcock (Fig. 24.1). Turn the valve stem so that it is off to the
Luer-LokTM. Observe all three of the openings to determine which two of the ports are
open to allow airflow in that particular direction.
3. Turn the valve stem so that it is off to the left port of the three-way stopcock. Observe all
three of the openings to determine which two of the ports are open to allow airflow in that
particular direction.
4. Turn the valve stem so that it is off to the right port of the three-way stopcock. Observe all
three of the openings to determine which two of the ports are open to allow airflow in that
particular direction.
5. Set up a cuff pressure measurement system using the aneroid manometer, as shown in
Figure 24.2.
6. Suction any secretions in the pharynx and above the cuff thoroughly.
7. Attach the measurement system to the valve connection on the pilot balloon with the three-
way stopcock open to all directions. The cuff will automatically deflate, which will allow
equilibration between the manometer, the pilot tube, and the cuff.
8. Pull the syringe barrel back to 10 mL and attach it to the three-way stopcock.
9. Slowly inflate the cuff to MOV during peak inspiration. Record the peak pressure achieved
on the manometer during expiration on your laboratory report.
10. The maximum cuff pressure should be maintained at less than 20 to 25 mm Hg or 25 to
33 cm H2O. The pressure increases during exhalation when the tracheal diameter is
narrower. Do not exceed maximum cuff pressures during the exhalation phase.
11. Turn the stopcock off to the pilot tube. Detach the manometer system.
12. Attach the 10-mL syringe to the pilot tube. Remove the air from the cuff, measure it, and
record the volume on your laboratory report. Reinsert the air slowly back into the cuff.
13. Repeat steps 6 through 12 using MLT.
14. Repeat steps 6 through 12 using a Posey Cufflator™ (Fig 24.3).
Figure 24.1. A three-way stopcock. (Courtesy of Smith

Industries Medical Systems, Keene, NH.)
2679_Ch24_369-386.indd 371 07/02/13 4:45 PM

Figure 24.2. Cuff pressure measurements using an aneroid manometer. Figure 24.3. Cuff pressure
measurements using a Posey
Cufflator™.
EXERCISE 24.2 RESECURING AND REPOSITIONING OF AN ENDOTRACHEAL TUBE

AND ORAL HYGIENE
To perform this exercise, 1. Have your laboratory partner wash his or her hands, apply standard precautions and
you will need an intubated transmission-based isolation procedures as appropriate, and hold the endotracheal tube
mannequin with a Briggs securely in position while you perform the following steps. Note the position of the
adapter and large-bore endotracheal tube.
tubing attached to simulate 2. Wash your hands. Apply standard precautions and transmission-based isolation procedures
a clinical situation. The tube as appropriate. Do not apply gloves until the tape is prepared. Prepare the cloth tape for
should be secured with tape use to secure the endotracheal tube.
before the exercise. 3. Put on your gloves. Carefully cut and remove the tape currently securing the endotracheal
tube. Do not cut the pilot tube. Make sure the pilot tube is out of your way. Discard the
used tape in an infectious waste container.
4. Oral hygiene is crucial in an intubated patient. Brush the teeth, rinsing out the mouth with
sterile water. Suction with a Yankauer suction apparatus. You may use lemon glycerin
swabs to clean the mouth. Male patients may also be shaved at this time.
5. Move the endotracheal tube to the opposite side of the mouth. You may use a tongue
depressor to assist if the tongue prevents easy repositioning. Insert an oropharyngeal airway
into the mouth medially to the endotracheal tube.
6. Clean the patient’s face using a wet 4×4 gauze pad, removing as much of the previous
adhesive as possible.
7. Dry the skin with a clean towel or 4×4 gauze pad.
8. To enhance the adhesiveness of the tape, you may apply tincture of benzoin on a 4×4 gauze
to the patient’s skin. Do not spray or apply the liquid directly to the patient’s face from the
container or bottle.
9. Apply the tape using one of the methods practiced in Chapter 22. Ensure that the tube
position is correct. Secure the tape around the oropharyngeal airway to serve as a bite
block. Reassess correct tube placement when finished. Chart the procedure on your
laboratory report.
10. Repeat the exercise using a commercial endotracheal tube holder to secure the tube.
2679_Ch24_369-386.indd 372 07/02/13 4:45 PM

EXERCISE 24.3 EXTUBATION
1. Verify a physician’s order or protocol or assess “patient’s” readiness for extubation. Check
the chart or protocol for the appropriate Fio2 after extubation.
Suction and suction kits
Large-volume nebulizer
Large-bore corrugated tubing
Aerosol mask
Scissors
10-mL syringe
Intubation tray (see Chapter 22)
3. Assemble the equipment to deliver the appropriate Fio2.
4. Using your lab partner as the patient, explain the procedure and verify that the “patient”
understands.
6. Assess the “patient,” including pulse oximetry.
7. Place the “patient” in a high Fowler’s position.
8. Suction the “patient’s” endotracheal tube and pharynx thoroughly, as described in Chapter 21.
9. Remove the endotracheal tube tape or securing device and deflate the cuff completely.
Alternatively, the pilot tube may then be cut to ensure easy removal of any remaining air
during tube withdrawal.
10. Instruct the “patient” to take a maximum inspiration and remove the tube at peak
inspiration so that the vocal cords are completely abducted. An alternative method is to
have the “patient” cough, which will also maximally abduct the vocal cords.1
11. Apply the oxygen and humidity device on the “patient.”
12. Assess the “patient.” Determine the adequacy of spontaneous ventilation. Make particular
note of hoarseness or stridor. If stridor is present, racemic epinephrine aerosol may be
administered. If stridor worsens and the “patient’s” clinical situation deteriorates, reintubation
may be necessary.
13. Chart the procedure on your laboratory report.
EXERCISE 24.4 AIRWAY EMERGENCIES
Your instructor will provide 1. Remove the ventilator adapter and manually ventilate the mannequin. Can you ventilate the
you with an orally intubated mannequin? Does the air go in easily? Is there an air leak around the mouth or nose? Record
mannequin attached to a your observations on your laboratory report.
ventilator swivel adaptor and 2. Your action plan will depend on the cause of the airway emergency.
tubing connection. The A. If you cannot ventilate or air cannot enter easily and there does not appear to be an air
mannequin has one of the leak, the tube is most likely obstructed. Follow the steps below to troubleshoot the
following airway obstructed airway:
emergencies simulated: (1) Attempt to pass a suction catheter. Suction and lavage the airway to clear the
Cuff rupture obstruction. Attempt to ventilate. Assess the adequacy of ventilation.
Tube obstruction (2) If it is not possible to clear the obstruction, an emergent situation is at hand and the
Pilot tube leak patient should be extubated. Notify the nurse and physician. Emergency extubation
Pilot valve leak is a last resort and should not be performed unless all other attempts have failed.
(3) The next step in a spontaneously breathing patient is to deflate the cuff and assess
for adequate ventilation. If ventilation is adequate, the situation is less emergent and
the proper equipment and personnel can be assembled to reintubate under more
controlled circumstances.
(4) If the patient cannot be adequately ventilated, an emergent situation is at hand and
the patient should be extubated. Notify the nurse and physician. Extubate and
manually ventilate the mannequin with a mask while preparations for reintubation
are made.
2679_Ch24_369-386.indd 373 07/02/13 4:45 PM

B. If you are able to squeeze the manual resuscitator without difficulty but a leak is noted
from the mouth or nose, there is a problem with the cuff, pilot tube, or valve. In an
actual clinical situation, a conscious patient may even be able to vocalize. Follow the
steps below to troubleshoot a cuff leak:
(1) Attempt to reinflate the cuff as previously practiced. If successful, measure the cuff
pressure.
(2) Ventilate and assess for leaks.
(3) If the leak persists, visually inspect the pilot tube, balloon, and valve for any cuts,
nicks, or other signs of damage. If the pilot tube is damaged, refer to step (7).
(4) Reinflate the cuff and apply a hemostat to the pilot tube as shown in Figure 24.4.
Be cautious not to apply excessive pressure so that the tube is not permanently
crimped or damaged.
(5) Ventilate and assess for leaks.
(6) If clamping the pilot tube in step 4 eliminated the leak, most likely the pilot valve
is damaged. Gather the equipment and assemble a temporary inflating device as
shown in Figure 24.5 by using an appropriate size needle, three-way stopcock,
and syringe. Cut the pilot valve and inflating tube past the point of any damage.
Insert the needle into the remaining portion of the pilot tube and attach the
inflating device. Tape the entire assembly to a tongue depressor to prevent
accidental needle-stick injuries or dislodging of the needle. Reinflate the cuff,
measure the cuff pressure, and reassess ventilation.
(7) If the leak persists, it is likely that the cuff is ruptured. This is an emergent situation
if you cannot achieve adequate ventilation, and the patient should be extubated.
Notify the nurse and physician of the situation. Extubate and manually ventilate
the mannequin with a mask while preparations for reintubation are made.
3. Chart your assessment of the cause of the airway emergency and the corrective actions taken
4. Repeat steps 1 and 2 for the other three airway emergencies.
Figure 24.4. Clamping the pilot tube.
2679_Ch24_369-386.indd 374 07/02/13 4:45 PM

Severed one-way valve and inflating tube
Stopcock
Needle 10-mL syringe
Deflated cuff
Figure 24.5. Temporary inflation device for a

damaged pilot valve.
R E FE R E N C E S
1. American Association for Respiratory Care: AARC clinical practice guideline: Management of airway emergencies. Respir Care 40:749–760,
1995.
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2679_Ch24_369-386.indd 376 07/02/13 4:46 PM
Laboratory Report
CHAPTER 24: ARTIFICIAL AIRWAY CARE AND MAINTENANCE
Name: Date:
Data Collection
EXERCISE 24.1 Cuff Care
E X E R C IS E 24 . 1. 1 MIN IM A L L E AK TECHN IQUE (MLT)
Endotracheal tube size: _____________________________________
Position: _____________________________________________ cm
Cuff volume: _____________________________________________
E X E R C IS E 24 . 1. 2 MIN IM A L O CCL UDIN G VOL UME (MOV)
Endotracheal tube size: _____________________________________
Position: _____________________________________________ cm
Cuff volume: _____________________________________________
E X E R C IS E 24 . 1. 3 C U F F P R E S S URE MEASUREMEN T
Cuff pressure at MOV: _____________________________________
Volume at MOV: __________________________________________
Cuff pressure at MLT: ______________________________________
Volume at MLT: ___________________________________________
Cuff pressure using Posey Cufflator™: _________________________
Volume using Posey Cufflator™: ______________________________
EXERCISE 24.2 Resecuring and Repositioning of an Endotracheal Tube and Oral Hygiene
Chart the procedure:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
2679_Ch24_369-386.indd 377 07/02/13 4:46 PM

EXERCISE 24.3 Extubation
Chart the procedure:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
EXERCISE 24.4 Airway Emergencies
Can you ventilate? _________________________________________
Does air go in easily? ______________________________________
Is there an air leak around the mouth and nose? _________________
Chart your assessment of the airway emergency and corrective actions taken:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________

1. What type of artificial tracheal airway should be used for the following clinical situations? If more than one option is
indicated, include all appropriate choices with an explanation.
A. Patient in cardiac arrest
B. Patient with a suspected C1 fracture
C. 3-year-old patient with epiglottitis
D. Patient with paralyzed vocal cords
2679_Ch24_369-386.indd 378 07/02/13 4:46 PM

E. Patient with dysphagia and chronic aspiration
F. Patient with a fractured jaw
G. An alert stroke patient who cannot cough
2. Describe the safety precautions that should be taken during oral hygiene of the intubated patient. What emergency
equipment should be readily available?
3. You are called to the surgical ICU to assess Mrs. King, who had open heart surgery and is 20 hours postoperative.
Describe how you would assess her readiness for extubation.
4. Mr. Kee is intubated with a 7.5-mm orotracheal tube. He is in the ICU on a ventilator. The low-exhaled-volume alarm
is sounding and Mr. Kee is phonating. His respiratory rate is 32 breaths/minute, the heart rate is 122 bpm, and the
pulse oximeter is 89%. You measure the cuff pressure to be 30 cm H2O, and the pilot tube and valve are intact. What
would be your recommendations to remedy this situation?
5. What is the relationship between aspiration and ventilator-associated pneumonia?
6. Why is it important to measure cuff pressures?
2679_Ch24_369-386.indd 379 07/02/13 4:46 PM

2679_Ch24_369-386.indd 380 07/02/13 4:46 PM

STUDENT: DATE:
CUFF CARE
PERFORMANCE LEVEL
PERFORMANCE RATING
Performance Level:
NA = Not applicable
Performance Rating:


3. Verifies the size, type, and position of airway
4. Stabilizes the airway while removing fastenings
5. Performs mouth or stoma care
6. Moves the tube to a new location (ETT) (right, left, or center)
7. Applies new ties/tape holder/precut dressing (for tracheostomy) as indicated
8. Verifies the appropriate position by auscultation, tube markings
9. Demonstrates the cuff inflation to the MOV
10. Demonstrates the cuff inflation to the MLT
11. Demonstrates the cuff pressure measurement using a manometer and/or commercial cuff inflation device
FOLLOW-UP
13. Identifies the appropriate range for the cuff pressure to minimize tracheal damage, prevent VAP
2679_Ch24_369-386.indd 381 07/02/13 4:46 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch24_369-386.indd 382 07/02/13 4:46 PM


STUDENT: DATE:
EXTUBATION
PERFORMANCE LEVEL
PERFORMANCE RATING
Performance Level:
NA = Not applicable
Performance Rating:

2. Assembles and verifies the function of the oxygen and humidification device to be used postextubation

4. Positions the patient in a high Fowler’s position
5. Suctions the patient’s endotracheal tube and pharyngeal area thoroughly
6. Deflates the cuff and assesses cuff leak (>30% VT) and vocalization
7. Removes the ET tube tape or securing device
8. Instructs the patient to take a maximum inspiration and removes the tube at peak inspiration (or alternatively during maximal cough);
NOTE: do not remove tube during suctioning
9. Applies the oxygen and humidification device
10. Reassesses the patient to determine adequacy of spontaneous ventilation and airway patency; verifies patient comfort and attends to
patient needs
11. Encourages the patient to cough; periodically reassesses the patient
FOLLOW-UP
12. Recommends cool mist, steroids, or racemic epinephrine as indicated
2679_Ch24_369-386.indd 383 07/02/13 4:46 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch24_369-386.indd 384 07/02/13 4:46 PM


STUDENT: DATE:
ARTIFICIAL AIRWAY CARE
PERFORMANCE LEVEL
PERFORMANCE RATING
Performance Level:
NA = Not applicable
Performance Rating:

2. Ensures that an emergency replacement airway of the same size and type is available at the bedside

4. Verifies the size, type, and position of the airway
5. Suctions the tube and pharynx thoroughly
6. Performs mouth or stoma care
7. Stabilizes the airway while removing fastenings
8. Cleans and dries the patient’s face; uses adhesive removal product if needed
9. Moves the tube to a new location (ETT) (right, left, or center)
10. Reinflates the cuff with maximum volume of 10 mL
11. Applies new ties/tape/commercial tube holder; applies tincture of benzoin or similar skin protection product if indicated
12. Verifies the appropriate position by auscultation and tube markings
13. Demonstrates the cuff inflation to the MOV or the MLT
14. Demonstrates the cuff pressure measurement and adjusts to 20 mm Hg to minimize VAP
FOLLOW-UP
2679_Ch24_369-386.indd 385 07/02/13 4:46 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch24_369-386.indd 386 07/02/13 4:46 PM

CHAPTER Noninvasive Blood
Gas Monitoring
INTRODUCTION Monitoring devices are used to observe or record the cardiopulmonary status of a patient
on a continuous or intermittent basis without the need for removal of bodily fluids or
tissue. The medical community is increasing its use of noninvasive technology to
monitor blood gases and trends, and the use of the devices is extending to the home.1
Pulse oximeters, transcutaneous monitors, capnometers, and capnographs can provide
useful data for clinical decisions. In addition, these devices pose fewer risks to the
respiratory care practitioner (RCP) and patient from infectious hazards than invasive
techniques.
The data provided by noninvasive monitors should not replace invasive blood gas
analysis. They only provide an indirect measurement of blood gas parameters. RCPs
should obtain a baseline arterial blood gas to correlate with the noninvasive data.2
Noninvasive devices have significant limitations that must be thoroughly understood
because false-negative or false-positive findings may lead to inappropriate patient
treatment.3,4 When used appropriately, noninvasive monitors are cost effective and can
improve patient outcomes.5
OBJECTIVES 1. Practice communication skills needed to explain noninvasive monitoring procedures to the
Upon completion of this patient and verify understanding.
chapter, you will be able to: 2. Apply infection control guidelines and standards associated with equipment and procedures,
3. Select, assemble, operate, and maintain the appropriate monitoring device for a given clinical
situation.
4. Assess and correct malfunctions of noninvasive monitoring equipment.
5. Identify limitations of noninvasive monitoring devices and differentiate false-negative and
false-positive readings from reliable clinical data.
6. Interpret data obtained from noninvasive monitors and correlate the results to the patient’s
condition.
7. Practice medical charting of noninvasive monitoring procedures and data obtained.
8. Practice verbal communication skills needed to report results of data collection and make
recommendations or modifications to the patient care plan.
KEY TERMS
capnography infrared absorption tourniquet
capnometry monitoring transcutaneous
colorimetric phlebotomy
hypocapnia spectrophotometry
387
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Exercises
F 4×4 gauze F Ice water
F Adhesive tape F Intubated airway management trainer
F Alcohol prep pads F Mainstream or sidestream sensor and
F Barometer (mercury or aneroid) connectors
F Bucket or large basin F Nail polish: red, black, and green
F Calibration gas source for capnograph F Nail polish remover
F Calibration gas source for transcutaneous F Nonrebreathing masks
monitor F Oxygen gas source and regulator
F Capnograph F PPE
F Cotton balls F Pulse oximeter
F Disposable and nondisposable oximeter F Swivel ventilator adaptor and 50-mL
probes corrugated tubing
F Disposable cannula probe F Transcutaneous electrodes
F Disposable colorimetric capnometer (Easy F Transcutaneous oxygen/carbon dioxide
Cap II, Pedi-Cap) monitor
F Elastic phlebotomy tourniquet or blood pres- F Zero solution
sure cuff
F Finger Phantoms or FingerSimTM (pulse oxim-
eter accuracy-checking devices)
EXERCISE 25.1 PULSE OXIMETRY

EXERCISE 2 5 .1 .1 MEASUR EMEN T OF S AT U R AT I O N A N D P U LS E
F Pulse oximeter
F Probe
F Electrical power cord
F Alcohol prep pads
F Finger Phantoms or FingerSimTM (pulse oximeter accuracy-checking devices)
2. Visually inspect the power cord (if applicable), and probe the cable for any frayed or
exposed wires.
3. Plug the power cord into a three-prong electrical outlet, if applicable. If a battery-operated
oximeter is used, continuous monitoring could run down the battery and render the unit
inoperative.
4. Determine the accuracy of the pulse oximeter by using Finger Phantom or FingerSimTM
pulse oximeter accuracy-checking devices, if available, as shown in Figure 25.1. These come
preset with three levels of saturation (97%, 90%, and 80%). Place the Finger Phantom or
FingerSimTM in the holder and insert it into the pulse oximeter probe. Rhythmically squeeze
the tip of the Phantom or simulator to simulate pulse. Record the saturation reading on the
pulse oximeter for each level on your laboratory report.
5. Using your laboratory partner as the patient, introduce yourself to your “patient,” explain
the procedure, and verify that your “patient” understands.
6. With the “patient” seated comfortably, measure the “patient’s” pulse rate manually. Record
it on your laboratory report.
7. Select a site for the probe application. Clean it with an alcohol prep pad. Possible
application sites are shown in Figure 25.2.
8. Turn on the oximeter.
9. Disinfect the probe if a nondisposable probe is used. Attach the probe to the selected site. If
a digit is selected, place the probe so that the light source is over the nail bed as you learned
in Exercise 6.4.
10. Measure the time required for equilibration and record it on your laboratory report.
11. Observe the pulse rate on the oximeter and correlate it with the manually measured rate.
Record any difference on your laboratory report.
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C H A P T E R 25 | N O N I N VA S I V E B LO OD GAS M ONITOR ING • 389
A B
Figure 25.1. (A) Finger Phantoms pulse oximeter accuracy-checking device. (Adapted from Nonin Medical, Inc., Plymouth,
MN with permission.) (B) FingerSim™. (Courtesy of BC Group International, Inc., St. Louis, MO.)
Infant
B
Adult nasal
A C
Neonatal/adult
Adult reflectance Ear clip
D E F
Figure 25.2. Oximeter probe application sites.
12. Record the saturation on your laboratory report.

13. If you are not able to obtain a reading, assess the capillary refill on the selected area.
Record your assessment on your laboratory report.
14. Remove the probe and disinfect it.
15. Chart the procedure on your laboratory report.
16. Using your laboratory partner as the nurse, report the results obtained and explain what
they mean.
17. Using your laboratory partner as the physician, report the results obtained and make any
necessary recommendations or modifications to the patient care plan.
EXER C ISE 25 .1 .2 EF FEC T O F N A I L P O LI S H O N S AT U R AT I O N

1. Using one color for each fingernail, polish each with two coats of the following colors:
F Black
F Red
F Green
2. Allow the nail polish to dry thoroughly.
3. Using the procedure outlined in Exercise 25.1.1, record the manual pulse, oximeter pulse,
and saturation level for each color on your laboratory report.
4. Remove and disinfect the probe.
5. Remove the nail polish if desired.
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EXERCISE 2 5 .1 .3 MODIFIED AL LEN ’S T E S T

Before performing the next exercises, conduct a modified Allen’s test on your laboratory partner.
(Look ahead to Exercise 26.2.) Note the results on your laboratory report.
EXERCISE 2 5 .1 .4 EF FEC TS OF PER FU S I O N C H A N G E S O N P U LS E O X I ME T R Y

1. Place ice water in a basin. Soak your hand in the ice water for several minutes.
2. Completely dry the iced hand. Using the procedure outlined in Exercise 25.1.1, record which
hand was used, the manual pulse, oximeter pulse, and saturation level obtained on your
laboratory report.
3. Using the opposite hand from that used in step 2, place an elastic phlebotomy tourniquet or
blood pressure cuff snugly around the biceps of the upper arm. If a cuff is used, inflate the
bladder until a radial pulse cannot be felt.
4. Using the procedure outlined in Exercise 25.1.1, record which hand was used, the manual
pulse, oximeter pulse, and saturation level obtained on your laboratory report.
5. Deflate the cuff or remove the elastic phlebotomy tourniquet as soon as you complete the
measurements.
EXERCISE 2 5 .1 .5 METABOL IC EFF ECT S O N P U LS E O X I ME T R Y

1. Use the procedure outlined in Exercise 25.1.1 for steps 2 to 4. For each step, record the
manual pulse, oximeter pulse, and saturation level obtained on your laboratory report.
2. With the pulse oximeter probe attached to your finger, hold your breath as long as possible.
Record the time of the breath hold.
3. Apply 100% oxygen via a nonrebreathing mask for 5 to 10 minutes.
4. Remove the oxygen mask. Run in place for several minutes. Record the duration of the
exercise.
EXERCISE 25.2 CAPNOGRAPHY

EXERCISE 25 .2 .1 DIS P OSABL E CAP N O ME T E R ( E A S Y C A P T M I I O R P E D I -C A P T M )
1. Obtain a disposable colorimetric capnometer and remove it from the wrapper.
2. Observe the face of the capnometer and note the ranges indicated, as shown in Figure 25.3.
Record the color of the capnometer and the ranges available on your laboratory report.
3. Remove the pull tab. Have your laboratory partner place the adaptor in his or her mouth
and breathe normally through the device. Note the change in color. Record the color changes
and the range observed on your laboratory report.
4. Identify the amount of dead space of the device. Record the amount on your laboratory
report.
Resuscitation bag or
breathing circuit connector
Colorimetric CO2
indicator
ET tube
connector
Figure 25.3. Colorimetric capnometer.
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C H A P T E R 25 | N O N I N VA S I V E B LO OD GAS M ONITOR ING • 391
EXER C ISE 25 .2 .2 C ON TINU O U S C A P N O G R A P H I C MO N I T O R I N G

1. Obtain the manual for the specific capnograph available in your laboratory.
2. Follow the instructions for the setup and calibration of the device. This usually requires a
zero-point calibration on room air and a high-point (slope) calibration gas of 5% carbon
dioxide (CO2). The calibration is usually performed every 12 to 24 hours, and the accuracy
should be within 12% or 4 mm Hg.4 Record the following on your laboratory report:
F Barometric pressure
F Percent CO2 used
F Calculation of slope calibration point
F Adjust the readings to the calibration points calculated.
3. Note the location of the sensor placement relative to the patient’s airway. Is this a
mainstream or sidestream sampling system? Examples of these two types of setups are
shown in Figures 25.4 and 25.5. Record your answer on your laboratory report.
4. Attach a cannula sensing device to the capnograph (Fig. 25.6).
5. Using your laboratory partner as the patient, explain the procedure and verify that your
“patient” understands.
6. Place the cannula on your “patient.”
7. Instruct the “patient” to breathe normally through the nose. Observe the time required for
the reading to stabilize. If the device has printer capabilities, obtain a capnogram and attach
it to your laboratory report. If the unit does not have a printer, observe the shape of the
capnograph wave and draw a facsimile of the observed tracing on your laboratory report.
8. Instruct your partner to breathe through the mouth. Observe the reading and record any
changes in the reading on your laboratory report.
9. Instruct your partner to breathe slowly and shallowly. Obtain a capnogram or draw a
facsimile of the observed tracing. Record the carbon dioxide level.
10. Instruct your partner to breathe quickly and deeply. Obtain a capnogram or draw a
facsimile of the observed tracing. Record the carbon dioxide level.
11. Instruct your partner to hold his or her breath. Record the length of the breath hold and
the CO2 level once the breath is released. Obtain a capnogram or draw a facsimile of the
observed tracing.
12. Dispose of the cannula in the proper receptacle.
13. Set up the device on an intubated mannequin (Fig. 25.7).
Figure 25.5. Sidestream capnography. (Courtesy of

Figure 25.4. Mainstream capnography. (Courtesy
Philips Respironics/Novametrix Medical Systems
of Philips Respironics/Novametrix Medical Systems
Inc., Murrysville, PA.)
Inc., Murrysville, PA.)
Figure 25.6. Cannula for capnography monitoring electrodes. (Courtesy of Philips

Respironics/Novametrix Medical Systems Inc., Murrysville, PA.)
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Elbow
To patient
CO2 sensor
Adult airway
adapter
To ventilator
Figure 25.7. Application of a capnograph sensor to
an artificial airway.
EXERCISE 25.3 TRANSCUTANEOUS MONITORS
1. Obtain a transcutaneous monitor and electrodes (Fig. 25.8).

2. Read the manual and determine whether the monitor is a Ptcco2, Ptco2, or a combined
unit. Record the type of unit on your laboratory report.
3. Following the manufacturer’s instructions, calibrate the unit using the appropriate zero
solution and slope gas.
4. Select an electrode site that is away from flat, bony areas, large veins, or thick skin. Possible
site selections are shown in Figure 25.9.
5. Cleanse the selected site with an alcohol prep pad and dry it.
6. Using your laboratory partner as the patient, explain the procedure and verify that your
“patient” understands.
7. Attach the electrode as directed in the manual. Record the location on your laboratory
report.
8. Adjust the temperature to 44°C to 45°C.
9. Observe the length of time required for equilibration.
10. Record the PTCCO2 and PTCO2 readings on your laboratory report.
11. With the electrode still in place, place your laboratory partner on a nonrebreathing mask
and record the PTCCO2 and PTCO2 readings on your laboratory report.
12. With the electrode still in place, instruct your laboratory partner to hold his or her breath.
Record the PTCCO2 and PTCO2 readings on your laboratory report.
13. Repeat the exercise, placing the electrode in one of the following locations:
F Palm of the hand
F Sole of the foot
F Underside of the forearm
F Clavicle
Record the site selected on your laboratory report. Observe the length of time required for
equilibration and record any differences in readings. Record the PTCCO2 and PTCO2 readings
14. Detach the electrode and clean it as instructed in the manufacturer’s manual.
15. Shut off the unit and clean it as required.
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C H A P T E R 25 | N O N I N VA S I V E B LO O D GAS M ONITOR ING • 393
Transcutaneous monitor
Electrode
Figure 25.8. Transcutaneous monitor
and electrode.
Figure 25.9. Site selection for transcutaneous

monitor placement. Adult Neonate
R E FE R E N C E S
1. Thompson, JE, and Jaffe, MB: Capnographic waveforms in the mechanically ventilated patient. Respir Care 50:100–109, 2005.
2. Cairo, JM, and Pilbeam, SP: Mosby’s Respiratory Care Equipment, ed. 8. Mosby, St. Louis, 2010.
3. American Association for Respiratory Care: AARC clinical practice guideline: Pulse oximetry. Respir Care 36:1406–1409, 1991.
4. American Association for Respiratory Care: AARC clinical practice guideline: Transcutaneous blood gas monitoring for neonatal & pediat-
ric patients—2004 revision and update. Respir Care 49:1069–1072, 2004.
5. Walsh, BK, Czervinske, MP, and DiBlasi, RM: Perinatal and Pediatric Respiratory Care, ed. 3. Saunders,
St. Louis, 2010.
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Laboratory Report
CHAPTER 25: NONINVASIVE BLOOD GAS MONITORING
Name: Date:
Data Collection
EXERCISE 25.1 Pulse Oximetry
E X E R C IS E 25 . 1. 1 ME A S U R E MEN T OF SATURATION AN D PUL SE
PULSE OXIMETRY ACCURACY CHECK
97% Phantom or FingerSimTM reading: ____________________________________
Manual pulse measurement: ___________________________________________
Oximeter equilibration time: ____________________________________________
Pulse difference: ____________________________________________________
SpO2: ______________________________________________________________
Capillary refill: _______________________________________________________
Charting: ____________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
E X E R C IS E 2 5 . 1. 2 E FF E C T O F N AIL POL ISH ON SATURATION
BLACK NAIL POLISH RED NAIL POLISH GREEN NAIL POLISH

SpO2
Oximeter pulse rate
Manual pulse measurement
E X E R C IS E 25 . 1. 3 MO D IF IE D A LL EN ’ S TEST
Modified Allen’s test result: _____________________________________________________________________________________
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E XE RCI SE 2 5 .1 . 4 E FF E C T S O F P E R FU S IO N C HAN GES ON PUL SE OXIMETRY
Iced Hand
Hand used: _________________________________________________________
SpO2: ______________________________________________________________
Oximeter pulse rate: __________________________________________________
Tourniquet or Blood Pressure Cuff
Hand used: _________________________________________________________
SpO2: ______________________________________________________________
E XE RCI SE 2 5 .1 . 5 ME TA B O L IC E FF E C T S O N P UL SE OXIMETRY
Pulse Oximeter Readings With Breath Hold
Time of breath hold: __________________________________________________
SpO2: ______________________________________________________________
Pulse Oximeter Readings With 100% Oxygen
SpO2: ______________________________________________________________
Pulse Oximeter Reading After Exercise
Duration of exercise: _________________________________________________
SpO2: ______________________________________________________________
EXERCISE 25.2 Capnography
E XE RCI SE 2 5 .2 . 1 D IS P O S A B L E C A P NO ME T ER (EASY CAP TM II OR PEDI-CAP TM )
Initial color: _________________________________________________________
Ranges available: ____________________________________________________
Color change: _______________________________________________________
Range measured: ____________________________________________________
Dead space: ________________________________________________________
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E X E R C IS E 25 . 2. 2 C O N T IN U O U S CAPN OGRAPHIC MON ITORIN G
Barometric pressure: _________________________________________________
Tracing of tidal breathing: ______________________________________________
Percent CO2 used: ___________________________________________________
Calculation of slope calibration point: ____________________________________
Show your work.
Mainstream or sidestream? _____________________________________________________________________________________
Observed differences between nose and mouth breathing:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Tracing of bradypnea: _____________________________ Tracing of tachypnea: _________________________________________
CO2 level = ______________________________________________ CO2 level = _________________________________________
Tracing of breath hold: _________________________________________________________________________________________
CO2 level = _________________________________________________________
Length of breath hold = ________________________________________________
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EXERCISE 25.3 Transcutaneous Monitors
Type of device used: __________________________________________________
Electrode placement site: ______________________________________________
PTCCO2: _____________________________________________________________
PTCO2: _____________________________________________________________
Nonrebreathing Mask
PTCCO2: _____________________________________________________________
PTCO2: _____________________________________________________________
Breath Hold
PTCCO2: _____________________________________________________________
PTCO2: _____________________________________________________________
New electrode placement site: _________________________________________
PTCCO2: _____________________________________________________________
PTCO2: _____________________________________________________________
Differences observed: _________________________________________________________________________________________
____________________________________________________________________________________________________________

1. What would the Pao2 be for a patient with an Spo2 of 90%? What would the Pao2 be for a patient with an Spo2 of
85%? What would the Pao2 be for a patient with an Spo2 of 75%? Using the O2Hb dissociation curve, explain the
correlation between Pao2 and Sao2.
2. Identify four limitations to the use of a pulse oximeter compared with a CO-oximeter. Explain how each limitation
would affect the accuracy or reliability of the Spo2 reading.
3. Describe how a pulse oximeter could be used to wean a patient from oxygen.
2679_Ch25_387-408.indd 398 07/02/13 4:46 PM

4. A 22-year-old patient who has recently started taking Dapsone for a dermatitis condition is admitted to the emergency
department. The patient’s skin is slate gray. The patient is unconscious, with shallow respirations and does not respond
to painful stimuli. The patient is intubated and resuscitated with 100% oxygen. Following intubation, the Spo2 re-
mains at 85% and the patient remains cyanotic. What procedure should be done to accurately diagnose this patient?
What is the treatment of choice for this patient?
5. Explain the use of capnography for trending in mechanically ventilated patients. What factors might affect the trends,
related to false-negative or false-positive findings?
6. Identify three conditions in which the capnography reading is lower than the Paco2.
7. In what conditions would the capnography reading be most comparable with the Paco2 in a mechanically ventilated
patient?
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8. Calculate the VD/VT ratio and the dead space (in milliliters) for each patient. Explain the significance of the VD/VT and
dead space measurements for each patient.
A. A spontaneously breathing COPD patient

PETco2 = 30 mm Hg
Paco2 = 60 mm Hg
VT = 400 mL
B. A drug overdose patient

PETco2 = 55 mm Hg
Paco2 = 60 mm Hg
VT = 500 mL
C. A head injury patient

PETco2 = 28 mm Hg
Paco = 30 mm Hg
VT = 800 mL
D. A patient with pulmonary emboli

PETco2 = 20 mm Hg
Paco = 45 mm Hg
VT = 600 mL
9. What is the normal VD/VT? What is the significance of a high dead space to tidal volume ratio?
10. Compare and contrast the mainstream and sidestream capnometer.
11. Identify four factors that would make the Ptco2 reading monitoring unreliable.
2679_Ch25_387-408.indd 400 07/02/13 4:46 PM

12. What are three key features of an acceptable PETco2 waveform?
13. In what way do transcutaneous values normally differ from arterial values?
14. How often and when should calibration of a transcutaneous monitor be performed?
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2679_Ch25_387-408.indd 402 07/02/13 4:46 PM

STUDENT: DATE:
PULSE OXIMETRY
PERFORMANCE LEVEL
PERFORMANCE RATING
Evaluator: Setting:
Performance Level:
NA = Not applicable
Performance Rating:

2. Determines FIO2 and/or ventilator settings
3. Visually inspects the power cord (if applicable) and probe cable for any frayed or exposed wires

5. Assesses the patient by measuring the patient’s pulse rate manually and/or by verifying the heart rate displayed on ECG monitor
(if applicable)
6. Confirms the FIO2 and/or ventilator settings in the patient’s room
7. Turns on the oximeter and allows for appropriate warm-up
8. Selects a site for the probe application and checks for adequate perfusion; removes nail polish or artificial nails if necessary
9. Cleans the site and nondisposable probe with an alcohol prep pad
10. Attaches the probe to the selected site and secures
11. Allows for proper stabilization
12. Observes the pulse rate on the oximeter and correlates it with the manually measured rate and/or ECG rate
13. Records the pulse rate, saturation, respiratory rate, and pattern
FOLLOW-UP
15. Disconnects and turns the unit off if it is not a continuous monitoring situation
16. Disinfects the probe if it is nondisposable
2679_Ch25_387-408.indd 403 07/02/13 4:46 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
to modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch25_387-408.indd 404 07/02/13 4:46 PM


STUDENT: DATE:
CAPNOGRAPHY/CAPNOMETRY
PERFORMANCE LEVEL
PERFORMANCE RATING
Evaluator: Setting:
Performance Level:
NA = Not applicable
Performance Rating:

2. Determines and verifies the FIO2 and ventilator settings
3. Calibrates the capnograph with 3% or 5% CO2 gas if required by the procedure manual

5. For a colorimetric capnometer, attaches to a 15-mm ETT adaptor and notes the color change and percent CO2 range; NOTE: Most de-
vices may be used up to 2 hours, do NOT discard after one measurement
6. For spot check or continuous capnograph monitors, turns the unit on and allows warm-up time
7. Connects a clean sampling sensor to the patient’s nose or in line to the ventilator circuit with a proper adaptor
A. Ensures that there is no excess pull on airway
B. Records the highest PETCO2 after 3 minutes and compares to a recent PaCO2
8. Analyzes and prints a capnograph wave if applicable and determines the ventilatory status
9. Calculates the VD/VD ratio (PaCO2 – PETCO2/PaCO2) and approximate dead space volume (VT x VD/VT)
10. Interprets results
FOLLOW-UP
12. If continuous monitoring is performed, checks the sensor or sampling line and water trap for moisture or debris and clears or replaces if
needed
2679_Ch25_387-408.indd 405 07/02/13 4:46 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
to modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch25_387-408.indd 406 07/02/13 4:46 PM


STUDENT: DATE:
TRANSCUTANEOUS MONITORING
PERFORMANCE LEVEL
PERFORMANCE RATING
Evaluator: Setting:
Performance Level:
NA = Not applicable
Performance Rating:

2. Calibrates the unit using the appropriate zero solution and slope gas

4. Assesses the patient and confirms the FIO2 and ventilator settings
5. Selects an electrode site away from flat, boney areas, large veins, or thick skin
6. Cleanses the selected site with an alcohol prep pad and dries it
7. Adjusts the temperature to 43°C–45°C as appropriate for the patient’s age
8. Allows for equilibration
9. Records the PTCCO2 and PTCO2 readings as applicable
10. Reassesses the patient and electrode site periodically; changes the electrode placement every 2 to 6 hours as indicated
FOLLOW-UP
2679_Ch25_387-408.indd 407 07/02/13 4:46 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
to modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch25_387-408.indd 408 07/02/13 4:46 PM

CHAPTER Arterial Blood Gas
Sampling
INTRODUCTION Arterial blood gas sampling is a quick and reliable tool for patient assessment. Blood
sampling from a peripheral artery or an indwelling catheter provides a specimen for the
measurement of pH and partial pressure of carbon dioxide and oxygen. When coupled
with co-oximetry, it is possible to obtain additional diagnostic indicators such as total
hemoglobin, hemoglobin saturation, and abnormal hemoglobins. Analysis of these
values helps evaluate the acid-base balance, adequacy of ventilation and oxygenation,
and the ability of the blood to carry oxygen. The analysis is used to assess a patient’s
response to therapeutic interventions, for diagnostic evaluations, and to monitor the
severity and progression of a disease process.1
Arterial blood sampling is an invasive procedure and is not without risk to both the
patient and the respiratory care practitioner (RCP). It is essential that the RCP practice the
required skills until proficiency is achieved before performing these procedures in the
clinical setting. Knowledge of anatomy and infection control practices is an integral part
of the requirements for safe technique. It should also be noted that although this chapter
primarily covers arterial blood gas sampling, in some instances RCPs might be involved
in obtaining capillary samples from young patients or analyzing venous blood samples.
OBJECTIVES 1. Practice communication skills needed to explain blood sampling procedures to patients.
Upon completion of this 2. Review medical charting and documentation of performance of blood gas sampling
chapter, you will be able to: procedures.
4. Assemble and prepare the equipment necessary for performance of arterial puncture and
arterial line sampling.
5. Review the medical record for information essential to the safe performance of arterial
sampling.
6. Demonstrate the safe performance of arterial puncture and arterial line sampling.
7. Demonstrate safe postpuncture care.
8. Prepare an anaerobic blood gas sample for transport.
9. Identify the equipment and steps necessary to perform a capillary sample for blood gas
analysis.
KEY TERMS
acid exsanguination intraflow perforate
anticoagulant hematoma Iodophor point-of-care
base hemoglobin lancet valve stem
bevel hemolysis latex
coagulopathy hemorrhage Luer-Lok™
409
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Exercises
F 1,000-units/mL heparin vials (optional) F Goggles
F Air bubble venting devices (optional) F Heparinized capillary tubes
F Arterial arm simulators F Lancets
F Arterial blood gas kits or component parts F Metal mixing “fleas” and magnet
F Arterial line setup: F Preheparinized syringes, 1, 3, or 5 mL
F 20-gauge intracath needle F Ice
F Heparin 1% solution F Iodophor or alcohol-based disinfectant pads
F Intraflow flush device F Patient label
F IV tubing F Red dye
F Three-way stopcocks F Rubber capillary tube stoppers
F Two 1,000-mL IV solution bags F Sample blood gas analysis slips
F Pressure bag F Self-capping syringes (optional)
F Band-Aid® bandages F Sharps containers
F Biohazard bags F Sterile drape (optional)
F Cloth tape F Sterile water
F Disposable gowns (optional) F Syringe caps and rubber stopper
F Disposable latex and vinyl gloves, various F Towels
sizes F Various size needles: 20, 22, 23, and
F Gauze, 4×4 and 2×2 25 gauge
EXERCISE 26.1 PREPARATION OF BLOOD GAS KIT COMPONENTS
1. Obtain an arterial blood gas kit. If preprepared kits are not available, gather the necessary
items and identify the following components:
Syringe. Record the size syringe on your laboratory report.
Needles, various sizes. Record the needle gauges available in your kit on your
laboratory report.
Iodophor or alcohol prep pads
Band-Aid® bandages
Label
Biohazard transport bag
Syringe cap and rubber stoppers
Self-capping device (optional)
Sterile or clean drape (optional)
Gauze
Liquid heparin vial (optional). Syringes may already be preheparinized with liquid
sodium heparin or dry litholized lithium heparin. Record the type of heparin used in
your blood gas kit.
Air bubble removal device/cap (optional). This may be available with kits that contain
self-capping needle protection devices (Fig. 26.1).
2. Wash your hands and apply latex or vinyl gloves.
NOTE: Some people have or may develop severe latex allergies.2 Vinyl gloves are recommended
in this case.
3. Select the smallest needle available in your kit for performing a radial puncture. Record the
gauge selected on your laboratory report.
4. Secure the needle on the syringe by twisting it onto the Luer-Lok™ (see Fig. 26.1).
5. If a preheparinized dry heparin syringe is used, draw back the plunger to preset the desired
sample amount to be obtained. In most modern blood gas analyzers, as little as 0.5 mL is
needed, but it is advisable to draw some extra blood in case repeat analysis is required.
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C H A P T E R 26 | A R T E R I A L B LOOD GAS S AM P LING • 411
B
Figure 26.1. (A) Air bubble removal device. (B) Attaching the Luer-Lok™ needle protection device and needle to the syringe. (Adapted from Smiths Industries Medical
Systems, Inc., Keene, NH.)
6. If a liquid heparin preheparinized plastic syringe is used, pull back the barrel of the syringe
about halfway. Then turn the syringe so that the needle is pointing straight up (Fig. 26.2). To
eject any excess air, slowly push the barrel back up to the point at which the heparin enters
the needle. Turn the needle and syringe downward and safely discard any excess solution.
Leave only the amount of heparin needed to fill the hub of the syringe and the needle. If a
glass syringe is used, the barrel of the syringe must be lubricated with the heparin before
ejecting the excess. This can be accomplished by sliding the barrel of the syringe up and
down until it slides freely on its own.
7. Gently loosen the needle cap but do not remove it.
8. Your instructor will give you a patient scenario. Fill out the patient label, charge slip, or
both. Include the “patient” name, identification number and type of sample (e.g., arterial
versus venous). Also note and record the “patient’s” temperature.
9. Before doing the procedure, take a moment and confirm that you are doing the correct
procedure on the appropriate “patient.”
2679_Ch26_409-432.indd 411 08/02/13 4:52 PM

Figure 26.2. Ejecting liquid heparin from a liquid

heparin syringe.
EXERCISE 26.2 MODIFIED ALLEN’S TEST
An arterial puncture can be Perform the following steps on your laboratory partner:
performed via the radial, 1. Identify your “patient.” Introduce yourself and your department. Explain to your partner in
brachial, or femoral artery nonmedical terms that you are going to perform an arterial blood gas sampling and what is
(Fig. 26.3). In general, involved. Verify that your partner understands and answer any questions or concerns. The
respiratory therapists are partner should simulate a patient’s concern and fears about having this invasive procedure
only permitted to perform performed and about the fact that laboratory personnel were just here drawing blood. You
radial and brachial should respond appropriately.
punctures. The radial artery 2. Confirm through chart review that there are no contraindications (e.g., vascular
is the most common site abnormalities) to drawing the sample from either hand.
chosen. It is the most 3. Determine which hand is the “patient’s” dominant hand. The nondominant hand is the
accessible, is easiest to preferred choice, but you should palpate both radial arteries and select the one with the
stabilize, and has the best strongest pulse. You can find the radial artery pulse by placing your index finger, middle
collateral circulation. A finger, or both on the lateral aspect of the wrist on the thumb side between the second and
modified Allen’s test third wrist folds, then sliding your fingers into the groove between the bones and tendons.
determines the presence of 4. Palpate the ulnar artery if possible. It is located on the lateral side of the wrist (closest to the
collateral circulation via the little finger) in the groove between the tendons and the ulnar bone.
ulnar artery. 5. Have the “patient” hold his or her hand palm up. Using two hands, occlude both the radial
and ulnar arteries as shown in Figure 26.4.
6. Instruct the “patient” to open and close his or her fist at least three times until you observe
the palm of the hand blanching (turning pale).
7. Release the ulnar artery only (pinky side of the “patient’s” hand). The palm should flush
within 3 to 5 seconds (10- to 15-second maximum).3 If not, repeat the test on the other arm.
8. Record the results of the Allen’s test on your laboratory report.
9. Practice the technique for performing a modified Allen’s test on an unconscious patient. Hold
the radial and ulnar arteries with one hand and raise the “patient’s” arm. Keep the arm
raised until the palm blanches. Lower the arm. Release the ulnar artery and look for the
palm flushing as in the preceding steps.
2679_Ch26_409-432.indd 412 08/02/13 4:52 PM

Figure 26.3. Sites available for arterial puncture.
Superficial
palmar arch
Ulnar Radial
artery artery
Figure 26.4. Performing the modified Allen’s test.
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EXERCISE 26.3 PERFORMANCE OF ARTERIAL PUNCTURE
Under no circumstances Perform or simulate the following steps:

should you draw blood on 1. Verify the “physician’s” order or protocol. Check for time and special instructions (on room
each other. Use an arterial air, with specified Fio2, immediately after ambulation, and/or special position). Also note
arm simulator for this and record the “patient’s” temperature.
procedure. Iodophor 2. Scan the chart and note the diagnosis, order, coagulopathies, anticoagulant therapy, oxygen
preparations will stain the concentration, and contraindications such as vascular abnormalities.
simulator and should be 3. Gather and prepare the required equipment as in Exercise 26.1. Fill the bag with ice and
avoided during laboratory water, but note that samples should not be iced for certain point-of-care blood gas analysis
practice. systems. Obtain a towel to use as a support for the “patient’s” wrist.
5. Introduce yourself and your department, and explain the procedure. Verify that your
“patient” understands. Reassure as needed.
6. Verify the “patient’s” identity by checking the identification band.
7. Verify the oxygen concentration or ventilator settings by double-checking in the room.
8. Fill in the patient information label, charge slip, or other appropriate documentation. In
some situations, this information may be input directly into a computer system. Include the
following information:4
Date
Time
Patient name and identification
Physician
Puncture site (left or right radial artery, arterial line, brachial artery, etc.)
Patient’s current temperature (obtained from the chart or nurses flow sheet)
Allen’s test results
Fio2: percent and modality
Ventilatory status: spontaneous respiratory frequency or ventilator settings, if
applicable, including machine tidal volume, machine frequency, mode of ventilation,
any spontaneous tidal volume, and frequency noted
Therapist signature
Record this information on your laboratory report. In a clinical situation, the label may be
filled out after the puncture procedure. However, ventilatory status and Fio2 should be
verified before the puncture.
9. Select the appropriate size needle and secure it to the syringe Luer-Lok™.
10. Heparinize the syringe or set the barrel on the preheparinized syringe as in Exercise 26.1.
11. Palpate both radial arteries. Choose the best site.
12. Perform the modified Allen’s test for the presence of collateral circulation as in
Exercise 26.2.
13. Position the “patient’s” arm so that it is extended and supported on a firm surface, palm
up. Place a towel or similar item to support the wrist (Fig. 26.5). Place a sterile or clean
field under the wrist if available.
14. Take a moment and confirm that you are doing the correct procedure on the appropriate
“patient.”
15. Prepare the intended puncture site by rubbing vigorously with antiseptic solution for at
least 30 seconds in a circular motion away from the puncture site. Allow it to dry. Disinfect
the gloved fingers that you will be using to palpate the pulse.
16. Repalpate the puncture site and determine the path of the artery.
Figure 26.5. Positioning of the wrist for a radial

artery puncture.
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17. Correctly perform the puncture.
A. Place your hand in the palm of the patient’s hand to stabilize it (Fig. 26.6).
B. With the bevel of the needle facing upward, enter the artery with the syringe at a 45°
angle. The puncture should be performed within 2 to 3 cm of the wrist skin folds.
Insert the tip of the needle quickly just through the skin, and then pause to verify the
needle angle.
C. Slowly advance the needle until a flash of blood is seen in the hub, indicating that the
artery has been entered. Once the flash is seen and blood begins to fill the syringe,
maintain your position until blood fills the syringe to the desired amount. The amount
needed will vary with the size of the syringe and the type of blood gas analyzer being
used. For most automated blood gas analyzers, 0.5 to 1 mL of blood is sufficient.
More may be obtained if more than one analysis will be performed on the sample. If a
flash of blood is not seen, slowly withdraw the needle to just below the surface of the
skin. Do not completely withdraw it. Redirect the needle angle until the blood is
obtained. Do not re-angle the syringe while it is in the wrist. There is no set rule as to
how many times redirecting the needle is acceptable. However, consider patient
comfort and the availability of another competent person to attempt the puncture. If
more than two or three redirections are needed, a beginning student should terminate
the procedure and seek assistance. If the needle accidently exits the subcutaneous tissue
or if an adequate sample cannot be obtained, a new ABG kit must be used to attempt
drawing the sample again.
NOTE: Arterial blood can be recognized by color, pulsation into syringe, self-filling, and data re-
sults as compared with clinical condition.
D. Remove the syringe and immediately compress the artery with the gauze.
E. Using the rubber stopper or self-capping needle protection device, plug the needle.
NOTE: Never recap the needle manually using two hands.
18. Continue to apply firm pressure to the site for 3 to 5 minutes or at least 10 minutes if the
“patient” has any bleeding disorders or is receiving anticoagulant therapy.
A B C
Figure 26.6. Radial artery puncture. (A) Stabilizing the patient’s hand. (B) Bevel position and needle angle for an arterial puncture. (C) Location of a radial artery
puncture.
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19. If a self-venting syringe is used, expel any air from the sample by pushing the barrel toward
the plugged needle. Otherwise, remove the needle from the Luer-Lok™ and expel the air
into a gauze pad. Venting devices may also be available. Once you have removed all air
bubbles, cap the syringe and label it.
20. Mix blood and heparin by rolling the syringe in your palms.
21. Place the sample on ice if analysis will be delayed by more than 15 minutes.1 Place the
sample in a biohazard bag for transport. Note that for certain point-of-care blood gas
analysis systems, samples should not be iced and must be run within 5 minutes of being
drawn.
22. Check the circulation distal to the puncture site. Continue to compress the artery until there
is a return of pulses proximal and distal to the site and there is no evidence of bleeding,
swelling, or discoloration.
23. Ensure “patient” safety and comfort.
24. Clean up. Discard needle in sharps container and dispose of any infectious waste in the
appropriate receptacle. Immediately clean any blood spills according to OSHA regulations
with a sodium hypochlorite (bleach) solution.
25. Remove your gloves and wash your hands.
26. Transport the sample in the sealed container.
27. Record the procedure on the chart and on appropriate departmental records, as applicable.
“Chart” the procedure on your laboratory report. Indicate whether the blood sample was
obtained and how many attempts were necessary.
28. Notify the “nurse” and raise the bed rail if it was originally lowered.
29. Repeat the exercise for a brachial artery puncture.
EXERCISE 26.4 ARTERIAL LINE SAMPLING

EXERCISE 2 6.4.1 AR TER IAL L IN E S E T U P
In this exercise, you are Identify the components of the arterial line setup shown in Figure 26.7 and record the corre-
simulating entering the room sponding letters on your laboratory report.
of a patient in contact Proximal three-way stopcock
isolation. The instructor will Luer-Lok™
have the “room” prepared Intraflow flush device
with equipment to be Monitor
discarded and to be Pressure tubing
transported. Arterial catheter
Pressure infuser
IV bag with heparinized solution
Transducer
Valve stem
Flush activator
EXERCISE 2 6.4.2 AR TER IAL L IN E S A MP LI N G

You should use an arterial Perform or simulate the following steps:
arm simulator for this 1. Verify the “physician’s” order. Check for time and special instructions (on room air, with
procedure. specified Fio2, and/or special position). Also note and record the “patient’s” temperature.
2. Scan the chart and note the diagnosis, anticoagulant therapy, Fio2 and modality, and
ventilator settings.
3. Gather and prepare the required equipment:
Discard or waste syringe, 5 mL or 10 mL, nonheparinized
Heparinized syringe, 1, 3, or 5 mL
Syringe cap
4×4 gauze
Sterile field or towel
Alcohol prep pads
Patient label
Biohazard transport bag filled with ice and water, but note that samples should not be iced
for certain point-of-service blood gas analysis systems
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C H A P T E R 26 | A R T E R I A L B L OOD GAS S AM P LING • 417
A
C
K
G
H
B
D C
I
E
B
Figure 26.7. Identification of arterial line components.
5. Introduce yourself and your department, and explain the procedure. Verify that the
“patient” understands if possible and reassure.
6. Verify the “patient’s” identity by checking the identification band.
7. Verify the Fio2 or ventilator settings by double-checking in the room.
8. Heparinize one syringe or set the barrel on the preheparinized syringe as in Exercise 26.1.
9. Place a sterile field or towel under the sampling site to prevent infection and soiling.
10. Check waveform and pressure readings on the monitor to verify line function.
11. Alert the “nurse” that you are about to draw the blood and temporarily silence the arterial
line alarm.
12. Remove the Luer-Lok™ cap from the three-way stopcock closest to the catheter insertion
site. Place it aseptically on the sterile field or on a sterile gauze pad.
13. Wipe the Luer-Lok™ of the three-way stopcock with an alcohol prep pad.
14. Attach the nonheparinized discard syringe on the Luer-Lok™ of the three-way stopcock and
twist to secure (Fig. 26.8).
Figure 26.8. Attachment of a waste syringe to the

stopcock.
2679_Ch26_409-432.indd 417 08/02/13 4:52 PM

15. Turn the valve stem of the stopcock toward the intraflow flush device (Fig. 26.9).
16. Fill the discard syringe until all flush solution has been removed from the catheter and
whole blood begins to appear in the syringe.
17. Turn the valve stem of the stopcock back toward the Luer-Lok™, as shown in Figure 26.10,
and then remove the discard syringe.
18. Attach the heparinized sample syringe on the Luer-Lok™ of the three-way stopcock and
twist to secure. Turn the stopcock toward the intraflow flush device (Fig. 26.11). Fill it with
the desired amount of blood for the sample.
19. Turn the valve stem of the stopcock back toward the Luer-Lok™ and then remove the
sample syringe.
20. If a self-venting syringe is used, expel any air from the sample by pushing the barrel toward
the plugged needle. Otherwise, remove the needle from the Luer-Lok™ and expel the air
into a gauze pad. Venting devices may also be available. Cap the syringe.
21. Activate the intraflow flush device and flush the arterial line catheter until no blood is seen
in the catheter (Fig. 26.12).
22. Turn the valve stem of the stopcock toward the catheter (off to the “patient”). Place a 4×4
gauze pad under the Luer-Lok™ and activate the intraflow flush device to flush the Luer-
Lok™ clean (Fig. 26.13). Wipe the Luer-Lok™ and cap with alcohol and then recap the
Luer-Lok™ (Fig. 26.14).
23. Mix blood and heparin in the syringe by rolling the syringe in your palms.
24. Label the syringe. Place the sample on ice if analysis will be delayed by more than
15 minutes.3 Note that for certain point-of-care blood gas analysis systems, samples
should not be iced and must be run within 5 minutes of being drawn.
25. Ensure “patient” safety and comfort.
26. Notify the “nurse” and raise the bed rail if it was originally lowered.
27. Clean up. Dispose of any infectious waste in the appropriate receptacle. Dispose of the
discarded syringe in a sharps container. Immediately clean any blood spills according to
OSHA regulations with a bleach solution.
Figure 26.9. Draw waste solution into the syringe

until blood is obtained.
Figure 26.10. Removal of the waste syringe.
2679_Ch26_409-432.indd 418 08/02/13 4:52 PM

A B
Figure 26.11. Attachment of a sampling syringe to the arterial line. Draw the blood sample into the syringe until the desired
amount is obtained.
Figure 26.12. Flushing the arterial catheter by

pulling the intraflow control device.
Figure 26.13. Flushing the Luer-Lok™.
Figure 26.14. Recapped flushed line.
28. Fill in the patient information label, charge slip, and other appropriate documentation. In
some situations, this information may be input directly into a computer system. Include the
following information:
F Date
F Time
F Patient name and identification
F Sample site (left or right radial, brachial, or femoral line)
F Fio2: percent and modality
F Patient temperature
F Ventilatory status: spontaneous respiratory frequency or ventilator settings, if
applicable, including machine tidal volume, machine frequency, mode of ventilation,
any spontaneous tidal volume, and frequency noted
F Your signature
29. Reactivate the arterial line alarm and check waveform and pressure readings to verify line
function.
31. Transport the sample in a sealed biohazard container.
32. Record the procedure on the chart and on appropriate departmental records as applicable.
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EXERCISE 26.5 CAPILLARY SAMPLING
Capillary sticks may be used The procedure is difficult to simulate in the laboratory setting. Practice of the procedure will be
in infants and children to reserved for the clinical setting. You should identify the equipment needed for capillary heel sam-
approximate pH and PCO2 pling and review the procedure.
values. The sample may be 1. Gather the necessary equipment:
taken from areas with a F Disposable latex and vinyl gloves, various sizes
large capillary surface area F 2×2 gauze
such as the fingertip, F Iodophor or alcohol prep pads
earlobe, or (most commonly) F Band-Aid® bandages
on the lateral aspect of the F Cloth tape
heel of the foot in infants F Biohazard bag
only. Values obtained for PO2 F Sharps containers
are generally less reliable. F Towels or warm packs
For acid-base balance and F Ice
carbon dioxide tension to be F Heparinized capillary tubes
reliable, the heel must be F Rubber capillary tube stoppers
“arterialized” by warming F Metal mixing “fleas” and magnet
before capillary sampling.5 F Lancets
F Sample blood gas analysis slips
3. Warm the heel area for 5 to 10 minutes before the procedure to arterialize by wrapping the
heel in a warm soak. The heel should turn pink or red before you obtain the sample.
4. Prep the site by vigorously rubbing with Betadine or an alcohol prep pad to disinfect it
before puncture.
5. The acceptable locations for heel sticks are shown in Figure 26.15. Quickly puncture the
lateral or medial aspect of the heel with the lancet (Fig. 26.16). The lancet should penetrate
approximately 3 mm to ensure adequate blood flow.
6. Do not squeeze the heel. Blood should be flowing freely.
7. The initial drop of blood should be wiped away with gauze and discarded. Using the
heparinized capillary tube, draw the sample into the tube up to the red line, making sure
that no air bubbles are introduced.
8. Compress the puncture site with gauze until bleeding has stopped. An adhesive bandage
may then be applied.
Figure 26.15. Acceptable heel

puncture sites. Figure 26.16. Capillary stick of the heel.
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C H A P T E R 26 | A R T E R I A L B L OOD GAS S AM P LING • 421
9. Seal one end of the capillary tube with a rubber stopper. Introduce the metal flea into the
tube, and place the circular magnet over the tube. Cap the other end of the tube as shown
in Figure 26.17.
10. Mix the blood and heparin by sliding the magnet up and down the tube, thereby moving
the metal flea.
11. Label the sample as in previous exercises.
12. Ice the sample if analysis will be delayed, but note that samples should not be iced for
certain point-of-care blood gas analysis systems. Place the sample in a biohazard bag or
container for transport.
13. Raise bed rails if originally lowered to facilitate the procedure and notify the “nurse” that
you are done.
15. Make sure to remove the metal flea before analysis of the sample.
Figure 26.17. Capillary tube with metal flea and magnet.
R E FE R E N C E S
1. American Association for Respiratory Care: AARC clinical practice guideline: Sampling for arterial blood gas analysis. Respir Care 37:913–
917, 1992.
2. Reines, HD, and Seifert, PC: Patient safety: Latex allergy. Surg Clin North Am 85:1329–1340, 2005.
3. Wilkins, R, Sheldon, R, and Krider, S: Clinical Assessment in Respiratory Care, ed. 6. Mosby, St. Louis, 2010.
5. Walsh, BK, Czervinski, MP, and DiBlasi, RM: Perinatal and Pediatric Respiratory Care, ed. 3. Saunders, St. Louis, 2010.
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2679_Ch26_409-432.indd 422 08/02/13 4:52 PM
Laboratory Report
CHAPTER 26: ARTERIAL BLOOD GAS SAMPLING
Name: Date:
Data Collection
EXERCISE 26.1 Preparation of Blood Gas Kit Components
Syringe size used: _____________________________________________
Needle sizes available: _________________________________________
Type of heparin: _______________________________________________
Needle gauge selected for radial puncture: _________________________
EXERCISE 26.2 Modified Allen’s Test
Allen’s test result: _____________________________________________
EXERCISE 26.3 Performance of Arterial Puncture
Patient label/charge slip information: ______________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Chart the arterial puncture: _____________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
EXERCISE 26.4 Arterial Line Sampling
E X E R C IS E 26 . 4. 1 A R T E R IA L L IN E SETUP
A. _________________________________________________________________________________________________________
B. _________________________________________________________________________________________________________
C. _________________________________________________________________________________________________________
D. _________________________________________________________________________________________________________
E. _________________________________________________________________________________________________________
F. _________________________________________________________________________________________________________
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G. _________________________________________________________________________________________________________
H. _________________________________________________________________________________________________________
I. _________________________________________________________________________________________________________
J. _________________________________________________________________________________________________________
K. _________________________________________________________________________________________________________

1. Identify three conditions that would require compression of the artery for longer than 10 minutes during postpuncture
care. Identify one condition that would require compression of the artery for less than 5 minutes.
2. Identify at least four complications of arterial line sampling and state how each can be prevented.
3. You are performing a modified Allen’s test to the right arm on Ms. Gordon, a 22-year-old African American woman.
You notice that her fingertips are cold to the touch. After release of the ulnar artery, it takes 12 seconds for color to re-
turn to the palm. What actions should you take at this time? What are the possible causes of a negative Allen’s test in
this patient?
4. While performing an arterial puncture on Ms. Gordon, the patient in Critical Thinking Question 3, you encounter the
following difficulties. Describe all possible solutions for each problem.
A. The tip of the needle touches the bedside table before insertion into the patient.
B. The artery seems to roll away from the needle each time you approach it.
C. You are having difficulty feeling a pulse in the right (nondominant) arm.
D. You observe a blood flash in the hub of the needle, and then blood flow stops.
2679_Ch26_409-432.indd 424 08/02/13 4:52 PM

E. The patient attempts to jerk her arm away as you are inserting the needle.
F. You have reangled the needle three times and are still unable to get the blood sample.
G. You notice swelling under the puncture site when you remove the needle.
H. As you are corking the needle, you puncture your fingertip.
5. Why does the IV bag in an arterial line setup need to be pressurized?
6. You are attempting to obtain a sample from an arterial line and encounter the following difficulties. Identify the proba-
ble cause(s), if applicable, and describe all possible solutions to the problems.
A. You observe a blood backup halfway between the point of entrance of the catheter into the patient’s arm and the
sampling port.
B. You drop the Luer-Lok™ cap on the floor.
C. After removing the discard syringe from the Luer-Lok™, blood continues to flow onto the bed sheets.
D. As you are withdrawing the blood sample, the patient is moving her arm and blood is filling the syringe
intermittently.
E. After removal of the sample, you are unable to flush the catheter.
2679_Ch26_409-432.indd 425 08/02/13 4:52 PM

7. You are working in the special care nursery. Orders for capillary blood gas sampling have been written for several
patients. Describe why these orders are contraindicated for the following patients.
A. A 24-week-old neonate born 6 hours ago
B. A 32-week-old hypotensive neonate born 2 weeks ago
C. A 28-week-old neonate with documented polycythemia for 4 days
D. A 36-week-old neonate born 2 days prior with cyanotic hands and feet
E. A 42-week-old infant in renal failure with swollen hands and feet
8. When using the heel to draw a capillary blood gas why is it so important not to squeeze the foot after the heel
puncture?
2679_Ch26_409-432.indd 426 08/02/13 4:52 PM


STUDENT: DATE:
ARTERIAL PUNCTURE
PERFORMANCE LEVEL
PERFORMANCE RATING
Performance Level:
NA = Not applicable
Performance Rating:

Note: Never recap needle; any needle stick must be reported
2. Confirms the diagnosis, coagulopathies, anticoagulant therapy, oxygen delivery devices, FIO2, ventilator settings, patient allergies, and if
using local anesthetic

4. Palpates the patient’s pulse on both arms to determine the best puncture site; uses the nondominant arm, if possible
5. Performs a modified Allen’s test; if negative, repeats on the other arm
6. Prepares the puncture site by rubbing vigorously in a circular motion away from the puncture site with an antiseptic solution for at least
30 seconds; disinfects gloved fingers used for palpation
7. Administers an anesthetic if ordered
8. Correctly performs the puncture:
A. Sets the plunger on a self-venting syringe to obtain the desired amount of blood (enough for repeated analysis)
B. Holds the syringe at 45° angle, needle bevel up
C. Slowly inserts the needle between the second and third skin fold on the patient’s wrist; safely adjusts the needle angle if necessary
9. Obtains the sample; removes the needle and immediately applies pressure with a sterile gauze
A. Maintains pressure on the puncture site for a minimum of 3–5 minutes; 10 minutes or longer if the patient has a bleeding disorder or
uses anticoagulants
B. Checks the puncture site for bleeding, swelling, discoloration, and return of pulse proximal and distal to the puncture site
10. Corks the needle with a rubber stopper or automatic capping device
11. Ensures an anaerobic sample; removes air bubbles with a venting device or according to OSHA guidelines
FOLLOW-UP
13. Labels the sample; places in an iced, sealed biohazard container for transport
14. Documents the date, time, FIO2, puncture site, Allen’s test results, oxygen and ventilatory settings (if applicable), and therapist signature
15. Cleans any blood spills with sodium hypochlorite (bleach) solution
2679_Ch26_409-432.indd 427 08/02/13 4:52 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch26_409-432.indd 428 08/02/13 4:52 PM


STUDENT: DATE:
ARTERIAL LINE SAMPLING

PERFORMANCE LEVEL
PERFORMANCE RATING
Evaluator: Setting:
Performance Level:
NA = Not applicable
Performance Rating:

2. Verifies FIO2, oxygen delivery device, and/or ventilator settings
3. Confirms the diagnosis and previous blood gas results if available

5. Confirms the oxygen and/or ventilator settings; assesses oxygenation and ventilatory status
6. Observes the cardiac monitor for the shape and height of the arterial waveform
7. Identifies the line/intraflow device
8. Aspirates the flush into waste syringe, if applicable
A. Removes the cap from the stopcock hub; disinfects and places aseptically on a clean gauze or drape
B. Attaches the unheparinized syringe and turns the stopcock off to the intraflow device
C. Places the gauze under the stopcock while aspirating approximately 3–5 mL until the flush solution is removed and whole blood ap-
pears in the syringe from the patient line
D. Turns the stopcock off to the syringe; removes the syringe and disposes in a sharps container
9. Aspirates the sample:
A. Sets the plunger of the self-venting syringe for the desired amount of blood (enough for a repeat analysis)
B. Secures the heparinized syringe on a Luer-LokTM hub
C. Reopens the stopcock; collects the sample
D. Turns the stopcock off to the syringe and removes the syringe
10. Caps the syringe; removes air bubbles following OSHA guidelines
11. Mixes and labels the sample; places in a sealed biohazard container; sends the blood to be analyzed
12. Maintains the line:
A. Using intraflow, with the stopcock turned toward the Luer-LokTM, flushes the line to the patient for one pass of the screen
B. Turns the stopcock off to the patient; places a gauze under the hub; pulls the intraflow to flush the stopcock hub
C. Turns the stopcock off to the Luer-LokTM; disinfects the hub and cap with alcohol and replaces the cap on the hub
13. Checks the waveform and verifies line function
FOLLOW-UP
A. Discards all disposables; disposes of sharps in a puncture-proof container
B. Documents the date, time, FIO2 or delivery device, site, ventilation settings and status, therapist signature
2679_Ch26_409-432.indd 429 08/02/13 4:52 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch26_409-432.indd 430 08/02/13 4:52 PM


STUDENT: DATE:
CAPILLARY SAMPLING
PERFORMANCE LEVEL
PERFORMANCE RATING
Evaluator: Setting:
Performance Level:
NA = Not applicable
Performance Rating:


3. Warms the heel for 5–10 minutes
4. Evaluates the effectiveness of warming before performing the puncture
5. Selects the appropriate puncture zone (lateral or medial to the calcaneus)
6. Disinfects the puncture site
7. Quickly punctures the appropriate site with the lancet, no deeper than 3 mm
8. Ensures the free flow of blood and does not squeeze the heel
9. Wipes away the first blood drop with a sterile gauze
10. Draws the sample into a heparinized capillary tube
11. Ensures that no air bubbles are present
12. Compresses the puncture site and applies an adhesive bandage if required
13. Seals one end of the capillary tube with a stopper
14. Inserts the mixing flea and places a circular magnet over the tube
15. Caps the other end
16. Mixes the sample by sliding the magnet up and down the tube
17. Labels the sample according to facility policy
18. Transports the sample to the laboratory according to facility policy, icing if necessary
FOLLOW-UP
2679_Ch26_409-432.indd 431 08/02/13 4:52 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch26_409-432.indd 432 08/02/13 4:52 PM

CHAPTER Arterial Blood
Gas Analysis and
Maintenance
INTRODUCTION One of the most rapid and significant transformations in clinical practice that evolved
from physiological research is the development of modern, integrated blood gas
analyzers. The current analyzers are incredibly sophisticated, stable, and fast.1,2)
Traditionally, arterial blood gas analysis was performed in the clinical laboratory on a
bench-top analyzer. However, new technological advances have introduced portable
point-of-care analyzers to the intensive care unit to provide reliable acid-base
measurements at the bedside.3
Because very important clinical decisions are based on blood gas data, it is imperative
that these values come from reliable and well-maintained clinical laboratories and blood
gas equipment. A total quality assurance program for a blood gas laboratory should
include documented policies and procedures for the analysis of samples and machine
maintenance, verifiable technician competence, scheduled preventive maintenance of the
analyzers, performance of calibrations, quality control sampling, proficiency testing, and
documentation of sample analysis results. The review of patient data would include the
statistical analysis of sampling done and identifying whether procedures were indicated.
This chapter introduces the respiratory care practitioner (RCP) to the procedures involved
in maintaining a blood gas laboratory. Because of the significant expense of equipment
and reagents and the lack of real blood samples for programs that are not hospital
based, some of the procedures described may be performed only in the clinical setting.4
OBJECTIVES 1. Apply infection control guidelines and standards associated with equipment and procedures,
Upon completion of this according to OSHA regulations and CDC guidelines.
chapter, you will be able to: 2. Analyze an arterial blood gas sample for pH, Paco2, and Pao2 via a standard blood gas
analyzer.
3. Analyze an arterial blood gas sample for total hemoglobin and oxyhemoglobin saturation, and
measure abnormal hemoglobins with a co-oximeter.
4. Perform one- and two-point calibrations of blood gas analyzers.
5. Perform daily and weekly maintenance according to manufacturer’s specifications.
6. Remembrane a pH, Pco2, and Po2 electrode.
7. Analyze quality control test samples and document the results.
KEY TERMS
buffer point-of-care reagent standard deviation
diluent proficiency slope (SD)
433
2679_Ch27_433-452.indd 433 07/02/13 4:46 PM

Exercises
F 3-mL syringes with 22- or 23-gauge needles F Electrode membrane changing kits for pH,
F 4×4 gauze Pco2, and Po2
F 5.25% sodium hypochlorite (bleach) (1:10) F Electrode membrane changing tools and holder
solution F Goggles, disposable gowns (optional)
F Arterial blood gas syringes F Heparinized capillary sample tubes
F Barometer—mercury or anaeroid F Levey-Jennings plot
F Bench-top blood gas analyzer F Magnet and metal rods (“fleas”)
F Blank blood gas report forms or equivalent F Plastic specimen containers or equivalent
F Calculator (optional) F Point-of-care blood gas analyzer
F Calibration gases F Point-of-care testing cartridges
F Co-oximeter F Quality control test samples for analyzer and
F Cotton swabs co-oximeter
F Deproteinizing solution F Reagents: pH buffers, Po2 and Pco2 electro-
F Diluent lytes, flush solution, KCl solution, or KCl
donuts
F Disposable latex and vinyl gloves, various
sizes F Sharps containers
F Disposable waste containers F Stopwatch or watch with second hand
F Electrode cleaning solution F Zeroing solution
EXERCISE 27.1 BLOOD GAS ANALYSIS USING A BENCH-TOP BLOOD GAS ANALYZER
EXERCISE 27 .1 .1 IDEN TIF ICATION O F C O MP O N E N T S O F B E N C H -T O P B LO O D G A S
AN ALYZERS
1. Identify the brand of bench-top blood gas analyzer used for this exercise and record it on
2. Identify the controls on the control panel and record them on your laboratory report. Draw
a schematic representation of the location of these controls. Be sure to include the location of
the sampling ports and electrodes.
3. Locate the reagents and the waste receptacle. Record the pH of the buffers for the analyzer
4. Locate the calibration gases. Note the pressures on the gauges and record them on your
laboratory report. Note the concentrations of gases in the tanks and record them on your
laboratory report.
5. Locate the water bath (if applicable). Record the temperature on your laboratory report.
Count the rate of gases bubbling through the water bath for 15 seconds and record it on
6. Locate the barometer in your laboratory (Fig. 27.1).
Figure 27.1. Barometer.
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C H A P T E R 27 | A R T E R I A L B LO O D G A S A N A LY S I S AND M AINTENANC E • 435
7. Determine the barometric pressure in your laboratory and record it on your laboratory
report.
8. Calculate the calibration point for slope and balance based on your recorded barometric
pressure using the following formula:
P = (Barometric pressure – 47 mm Hg) × FI
where P is the partial pressure of calibration gas and FI is the fractional decimal expression
of the gas concentration. Show your work and calculations on your laboratory report.
EXER C ISE 27 .1 .2 C AL IBR AT I O N O F B E N C H -T O P B LO O D G A S A N A LY Z E R S

The specific sequence of steps of this exercise and your result will vary depending on the brand
and level of automation of the analyzer used. Consult the operator’s manual for the analyzer you
are using.
Two-Point Calibration
Initiate the two-point calibration sequence for your analyzer. Using a stopwatch or a watch with
a second hand, time how long the two-point calibration takes for your analyzer. Record the time
on your laboratory report. Pay attention to the sequence in which the calibration introduces the
reagents and gases into the analyzer. Record the sequence of reagents and gases on your labora-
tory report.
The following steps are usually involved in a two-point calibration:
1. Flush the pH electrode.
2. Introduce the low-pH buffer into the pH electrode.
3. Allow sufficient time for the reading to stabilize.
4. Adjust the pH balance control.
6. Introduce the high-pH buffer into the pH electrode.
7. Allow sufficient time for the reading to stabilize.
8. Adjust the pH slope control.
9. Calculate the balance and slope gas calibration points.
10. Introduce low-calibration gases into the Pao2 and Paco2 electrodes.
11. Allow sufficient time for the readings to stabilize.
12. Adjust the Po2 and Pco2 balance controls.
13. Flush the electrodes.
14. Introduce high-calibration gases into the Po2 and Pco2 electrodes.
16. Adjust the Po2 and Pco2 slope controls.
17. Flush the sampling chamber (if the machine does not flush automatically).
18. Determine from the analyzer manual or observation how often the machine performs a
two-point calibration. Record this information on your laboratory report.
One-Point Calibration
Initiate the one-point calibration sequence for your analyzer. Using a stopwatch or a watch with a
second hand, time how long the one-point calibration takes for your analyzer. Record the time on
your laboratory report. Pay attention to the sequence in which the calibration introduces the re-
agents and gases into the analyzer. Record the sequence of reagents and gases on your laboratory
report.
The following steps are usually involved in a one-point calibration:
2. Expose the pH electrode to the high-pH buffer.
4. Adjust the balance control.
6. Introduce the low-calibration gases.
8. Adjust the Pco2 and Po2 balance controls.
9. Determine how often the machine performs a one-point calibration. Record the frequency on
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EXERCISE 2 7 .1 .3 AN ALYSIS OF QUA LI T Y C O N T R O L T E S T ME D I A

Three levels of controls 1. Apply latex or vinyl gloves and other standard precautions and transmission-based isolation
must be analyzed every procedures as applicable.
8 hours and appropriately 2. Perform a one-point calibration before analysis.
documented. Depending 3. Verify the quality control medium expiration data and lot number. Record the type of
on the medium used, the quality control medium used on your laboratory report.
medium may need to be 4. Mix the quality control medium gently by swirling the vial. Break open the vial carefully,
anaerobically drawn up into and draw up an anaerobic sample of the level I medium into a syringe using a 22- or
sampling syringes before 23-gauge needle, or aspirate directly into the analyzer’s sampling tube. Use a glass ampule
insertion into the blood protection device if one is available (Fig. 27.2).
gas analyzer. The following 5. Initiate the sampling sequence on your analyzer.
instructions are for media 6. Insert the syringe into the sampling port (on some analyzers this may require inserting the
that come in small glass analyzer sampling tube into the syringe).
vials. If you use a different 7. Slowly inject the sample into the analyzer until a continuous line of the sample can be seen
medium, follow the past the electrode block or until the machine indicates that enough blood has been
manufacturer’s directions. introduced.
NOTE: Be certain that you do not introduce air bubbles. Most modern machines need less than
0.5 mL of sample. Older machines may need 1 to 2 mL.
9. Record the results on your laboratory report. Print out the results if a printer and blood gas
recording slips are available.
11. Discard the syringe and glass ampule in a sharps container.
12. Repeat the preceding steps with level II and level III and record the results on your
laboratory report.
13. If the control levels are out of range, take corrective actions. Record the actions you took
14. Remove your gloves and discard them in an infectious waste container. Wash your hands.
EXERCISE 2 7 .1 .4 TREN DIN G OF QUA LI T Y C O N T R O L D ATA : LE V E Y-J E N N I N G S P LO T S

For the following exercise, 1. Determine what method or methods of recording and analyzing quality control data your
you will need to obtain clinical site uses (manual or computerized). Record this information on your laboratory
quality control data from a report.
2-day period or longer and 2. Collect at least 2 day of quality control data for all shifts and levels. Attach this information
do statistical analysis. to your laboratory report.
3. Obtain the lot number of the quality control medium and the acceptable ranges for quality
control data for each level. Record this information on your laboratory report.
4. Obtain a printout or copy of a Levey-Jennings plot, as shown in Figure 27.3, from your
clinical site for the time period in which you collected your data. Attach it to your laboratory
report. Identify any values that indicate random error, trending, or out-of-control data.
Figure 27.2. Glass ampule protection device.
2679_Ch27_433-452.indd 436 07/02/13 4:46 PM

Figure 27.3. Sample Levey-

Jennings plot. C
2679_Ch27_433-452.indd 437 07/02/13 4:46 PM

EXERCISE 2 7 .1 .5 BL OOD GAS AN ALY S I S

Blood samples may not be Record the type of specimen you used on your lab report.
readily available in a school 1. Apply latex or vinyl gloves and other standard precautions and transmission-based isolation
laboratory setting. Do not procedures as applicable. You may wear gowns and goggles when dealing with human
introduce the red dye blood samples.
“blood” solution used in 2. Perform a one-point calibration before blood analysis.
the arterial arm simulators 3. Remove the blood sample from the ice bath and mix the sample by rolling it between your
into the blood gas analyzers. palms. Verify that it is an air-free sample.
You may use a saline or 4. Remove the cap from the sample syringe. Eject a small amount of blood into a gauze pad.
water solution or quality 5. Initiate the sampling sequence on your analyzer. Analyzers interfaced with computers may
control medium as a require that patient data and other information be entered.
substitute for blood 6. Insert the syringe into the sampling port (on some analyzers, this may require inserting the
samples. analyzer sampling tube into the syringe).
7. Slowly inject the blood sample into the analyzer until you can see a continuous line of
blood past the electrode block or until the machine indicates that enough blood has been
introduced. Be certain that you have not introduced any air bubbles or clots. Most modern
machines need less than 0.5 mL of blood. Older machines may need 1 to 2 mL. Newer
models aspirate the blood sample into the machine automatically.
9. Record the results on your laboratory report. Print out the results if a printer and blood gas
recording slips are available.
11. Discard the syringe in a sharps container.
12. Clean up any blood spills with a 1:10 solution of sodium hypochlorite (bleach) solution.
EXERCISE 2 7 .1 .6 MAIN TEN AN C E OF A B E N C H -T O P B LO O D G A S A N A LY Z E R

The steps required for daily and weekly preventive maintenance will vary depending on the type
of analyzer and the level of automation. Refer to the operator’s manual for specific sequences.
You should perform all activities with appropriate standard precautions, including gloves, gowns,
and goggles if blood splashing may occur.
Daily Maintenance
1. Empty or change the waste container. Modern analyzers may have disposable waste bottles.
Remove the container and replace it with a new one. If a disposable container is not
available, discard the waste in an infectious waste container, followed by a small amount of
bleach. Rinse the container with hot water, pour a small amount of bleach into the container,
and place it back onto the analyzer.
2. Check the calibration gas tank pressures.
3. Check the fluid and reagent levels.
4. Check the barometric pressure. Zero the base of the manometer if needed.
5. Verify that the water bath temperature is 37°C.
6. Check the water level in the humidifier (if applicable). Refill it (if needed) with sterile water.
7. Clean the sample port with a cotton swab and bleach solution or alcohol.
8. Remove bubbles and dry the electrode chambers if disposable electrodes are not being used.
Newer electrodes are maintenance-free.
Weekly or Biweekly Maintenance
1. Insert a syringe with cleaning solution once per week. Allow it to sit in the sampling chamber
for the time recommended in the manual. Flush the chamber when complete.
2. Insert a sample of deproteinizing solution. Allow it to sit in the sampling chamber for the
recommended time. Flush the chamber when complete.
3. Change the membranes. Newer electrodes on some brands of analyzers are maintenance-free.
The entire electrode block is replaced about once a year. Other brands have snap-on
membrane kits that are easier to remembrane.
The following steps are usually involved in membrane changing:
A. Remove the electrode from the machine.
B. Remove the old membrane, O-ring, and electrolyte solution.
C. Rinse with sterile water.
2679_Ch27_433-452.indd 438 07/02/13 4:46 PM

D. Polish the Po2 electrode tip with a small amount of pumice on a gauze pad and then
rinse with sterile water.
E. Soak the electrode in the appropriate solution.
F. Place a new O-ring on the appropriate membrane changing tool and insert it into the holder.
G. Place a new membrane over the tool, letters down.
H. Place a drop of electrolyte on the membrane.
I. For the CO2 electrode, place a nylon spacer over the tip of the electrode.
J. Insert the tip of the electrode into the tool and push down until the O-ring snaps into
place.
K. Inspect the membrane and remove any wrinkles. Trim if necessary and remove the
cardboard holder.
L. Fill the electrode with fresh electrolyte solution, leaving a 1-mm air bubble in the
chamber.
M. Dry the outside of the electrode and check for leaks. Place the “boot” over the tip of the
membrane.
EXERCISE 27.2 BLOOD GAS ANALYSIS USING POINT-OF-CARE TESTING

EXER C ISE 27 .2 .1 IDEN TIF I C AT I O N O F C O MP O N E N T S O F P O I N T-O F-C A R E T E S T I N G ( P O C T )
Analyzers
1. Identify the brand of point-of-care analyzer you used for this exercise and record it on your
laboratory report.
2. Identify the controls and cartridge port on the POCT analyzer. Draw a schematic of the
components of the analyzer including the control panel and location of the port.
3. Obtain and remove a cartridge from its pouch. Identify the contact pads and calibrant pack
in the center of the cartridge (Fig. 27.4). Record what happens when you press the center of
the cartridge.
EXER C ISE 27 .2 .2 P OIN T-O F-C A R E T E S T I N G B LO O D G A S A N A LY S I S

Blood samples may not be Record the type of specimen you used on your lab report.
readily available in a school 1. Apply latex or vinyl gloves and other standard precautions and transmission-based isolation
laboratory setting. Do not procedures as applicable. Gowns and goggles may be worn when dealing with human blood
introduce the red dye samples.
“blood” solution used in 2. Remove the cartridge from its pouch. Avoid touching the contact pads or exerting pressure
the arterial arm simulators over the calibrant pack in the center of the cartridge.
into the blood gas analyzers. 3. After thoroughly mixing the sample, remove the cap from the sample syringe. Eject a small
You may use a saline or amount of blood into a gauze pad.
water solution or quality 4. Verify that the sample is free of air, has not been iced, and has been run within 10 minutes
control medium as a of the ABG procedure.
substitute for blood 5. Direct the dispensing tip or capillary tube containing the blood into the sample well until it
samples. reaches the fill mark on the cartridge and the well is about half full.
6. Close the cover over the sample well until it snaps into place. (Do not press over the
sample well.)
7. Insert the cartridge into the cartridge port on the analyzer until it clicks into place.
NOTE: Never attempt to remove a cartridge while in the locked position.
Figure 27.4. POCT analyzer cartridge. (Adapted from Abbott Point

of Care, Inc. Princeton, NJ, with permission.)
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9. Enter an operator and patient ID number.
10. Select the tests to be reported, if prompted.
11. Enter additional parameters if required:
• Patient temperature in degrees Centigrade or Fahrenheit
• Patient Fio2 setting and ventilator settings
• Sample type being analyzed
12. View the results shown on the analyzer’s display screen. Record the results on your
laboratory report. Print out the results if a printer and blood gas recording slips are
available.
13. Discard the syringe and cartridge in a sharps container.
14. Clean up any blood spills with a 1:10 solution of sodium hypochlorite (bleach) solution.
EXERCISE 27.3 CO-OXIMETRY

EXERCISE 27 .3 .1 IDEN TIF ICATION O F C O N T R O LS FO R A C O -O X I ME T E R
1. Identify the brand of co-oximeter you used for this exercise, and record it on your laboratory
report.
2. Identify the controls on the control panel. Record them on your laboratory report. Draw a
schematic representation of the location of these controls.
3. Locate the reagents and waste receptacle. Record which reagents you used for the co-oximeter
EXERCISE 2 7 .3 .2 C AL IBR ATION AN D Q U A LI T Y C O N T R O LS FO R A C O -O X I ME T E R

The steps required for The following steps are usually involved for calibration and quality control for a co-oximeter:
calibration and quality 1. Activate the flush.
control media sampling 2. Aspirate the sample chamber.
will vary depending on the 3. Alternate between flush and aspirate until all bubbles are removed from the fluidics.
type of analyzer and the 4. Push the start button.
level of automation. Refer 5. Insert the calibration sample into the sample port.
to the operator’s manual 6. Once the readings stabilize, adjust the calibration value if necessary.
for specific sequences. 7. Repeat the procedure for the quality control media.
You should perform all
activities with appropriate
standard precautions and
transmission-based isolation
procedures, including gloves,
gowns, and goggles if blood
splashing may occur.
RE F E RE N CE S
1. Raff, H: The significance of the blood gas analyzer. APS 10:1152, 2004.
2. Severinghaus, JW, and Bradley, AF: Electrodes for blood Po2 and Pco2 determination. J Appl Physiol 13:515–520, 1958.
3. Shapiro, B: Point-of-care blood testing: More than simply changing venue. Chest 115(4):917–918, 1999.
4. American Association for Respiratory Care: AARC clinical practice guideline: In vitro pH and blood gas analysis and hemoximetry.
Respir Care 46(5):498–505, 2001.
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Laboratory Report
CHAPTER 27: ARTERIAL BLOOD GAS ANALYSIS AND MAINTENANCE
Name: Date:
Data Collection
EXERCISE 27.1 Blood Gas Analysis Using a Bench-Top Blood Gas Analyzer
E X E R C IS E 27 . 1. 1 ID E NT IFIC ATION OF COMPON EN TS OF BEN CH-TOP BL OOD GAS AN ALY ZERS
1. Analyzer brand: _________________________________________
2. Control panel:
________________________________________ ________________________________________
________________________________________ ________________________________________
________________________________________ ________________________________________
________________________________________ ________________________________________
________________________________________ ________________________________________
________________________________________ ________________________________________
________________________________________ ________________________________________
________________________________________ ________________________________________
________________________________________ ________________________________________
Schematic:
2679_Ch27_433-452.indd 441 07/02/13 4:46 PM

3. pH of the buffers: ________________________________________
4. Calibration gas pressures: ________________________________
Concentration of gases: ____________________________________
5. Water bath temperature: __________________________________
Bubbling rate: __________________________________ /15 seconds
6. Type of barometer: _______________________________________
7. Barometric pressure: _____________________________________
8. Calculation of calibration points (Show your work):
PB = ____________________________________________________
Slope gases: CO2 = ________________________ O2 = ____________________________________
Balance gases: CO2 = ______________________ O2 = ____________________________________
E XE RCI SE 2 7 .1 . 2 C A L IB R AT IO N O F B E NC H -TOP BL OOD GAS AN ALYZERS
Duration (time) of two-point calibration: ________________________
Sequence for reagents in two-point calibration: ______________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Frequency (time) between two-point calibrations: __________________
Duration of one-point calibration: _______________________________
Sequence for reagents in one-point calibration: ______________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Frequency of one-point calibration: ________________________________________________________________________________
E XE RCI SE 2 7 .1 . 3 A N A LY S IS O F Q U A L IT Y C O N TROL TEST MEDIA
Type of quality control medium used: _______________________________________________________________________________
Level I Level II Level III
EXPECTED RANGES EXPECTED RANGES EXPECTED RANGES
pH: ____________________________ pH: _________________________ pH: _________________________
Pco2: ___________________________ Pco2: ________________________ Pco2: ________________________
Po2: ____________________________ Po2: _________________________ Po2: _________________________
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ACTUAL RESULTS ACTUAL RESULTS ACTUAL RESULTS
pH: ____________________________ pH:__________________________ pH: _________________________
Pco2: ___________________________ Pco2: ________________________ Pco2: ________________________
Po2: ____________________________ Po2: _________________________ Po2: _________________________
Describe corrective actions (if applicable) if out of range:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
E X E R C IS E 27 . 1. 4 T R E N D ING OF QUAL ITY CON TROL DATA: L EVEY-JEN N IN GS PL OTS
1. Method(s) of recording and analyzing quality control data.
Clinical site: ______________________________________________
Method(s) used: __________________________________________
2. Quality control data: _____________________________________
3. Lot number: ____________________________________________
Acceptable ranges for quality control data:
Level I Level II Level III
pH: ____________________________ pH:__________________________ pH: _________________________
Pco2: ___________________________ Pco2: ________________________ Pco2: ________________________
Po2: ____________________________ Po2: _________________________ Po2: _________________________
4. Attach the Levey-Jennings plot. Identify any values on the attached plot that indicate:
A. Random error
B. Trending
C. Out of control
E X E R C IS E 27 . 1. 5 B L O O D G A S AN ALYSIS
Type of specimen used: _____________________ FIO2 _____________________________________
pH: ____________________________________
Paco2: __________________________________
Pao2: ___________________________________
Hco3–: __________________________________
Sao2: ___________________________________
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EXERCISE 27.2 Blood Gas Analysis Using Point-of-Care Testing
E XE RCI SE 2 7 .2 . 1 ID E NT IFIC AT IO N O F C O MPON EN TS OF POIN T-OF -CARE TESTIN G (POCT)
1. Analyzer brand: _________________________________________
2. Control panel:
________________________________________ ________________________________________
________________________________________ ________________________________________
________________________________________ ________________________________________
________________________________________ ________________________________________
________________________________________ ________________________________________
________________________________________ ________________________________________
________________________________________ ________________________________________
________________________________________ ________________________________________
________________________________________ ________________________________________
________________________________________ ________________________________________
Schematic of cartridge port location on POCT analyzer:
3. Result of pressure on center of POCT cartridge: __________________________
2679_Ch27_433-452.indd 444 07/02/13 4:46 PM

E X E R C IS E 27 . 2. 2 P O IN T-O F -C ARE TESTIN G BL OOD GAS AN ALYSIS
Type of specimen used: ____________________ FIO2 ____________________________________
pH: ____________________________________
Paco2: __________________________________
Pao2: ___________________________________
Hco3–: __________________________________
Sao2: ___________________________________
EXERCISE 27.3 Co-Oximetry
E X E R C IS E 27 . 3. 1 ID E NT IFIC ATION OF CON TROL S F OR A CO-OXIMETER
1. Brand of co-oximeter: ____________________________
2. Control panel:
________________________________________ ________________________________________
________________________________________ ________________________________________
________________________________________ ________________________________________
________________________________________ ________________________________________
________________________________________ ________________________________________
________________________________________ ________________________________________
________________________________________ ________________________________________
________________________________________ ________________________________________
________________________________________ ________________________________________
________________________________________ ________________________________________
Schematic:
3. Reagents used for the co-oximeter: __________________________________________
2679_Ch27_433-452.indd 445 07/02/13 4:46 PM


1. For each of the following, identify what it measures, describe the components of the device, and explain its principal of
operation.
A. Sanz electrode
B. Severinghaus electrode
C. Clark electrode
D. Co-oximeter
2. What effect will a water bath temperature of less than 37ºC have on the measured pH, Paco2, and Pao2? What effect
will a water bath temperature of greater than 37ºC have on the measured pH, Paco2, and Pao2? Whose gas law
explains this?
3. Why is it important to eject a small amount of blood from the syringe sample onto a gauze pad before injecting the
sample into the machine?
4. Under what circumstances and how often should a two-point calibration be performed on a blood gas analyzer? A
one-point calibration?
2679_Ch27_433-452.indd 446 07/02/13 4:46 PM

5. Given a barometric pressure of 750 mm Hg, calculate the calibration points for the following (Show your work):
A. 10% CO2 and 0% oxygen
B. 5% CO2 and 12% oxygen
C. 20% oxygen and 12% CO2
6. List four common preanalytical errors and four common postanalytical errors associated with blood gas sampling and
analysis and explain how each error can be avoided.
7. What are the components of a POCT sample cartridge?
8. What will happen to the results of an arterial blood gas sample that is exposed to air?
9. A patient is being treated for smoke inhalation and third-degree burns. Silvadene has been applied to large portions of
the patient’s body surface. How might the patient’s condition affect the analysis of blood for co-oximetry?
10. Identify three factors that would make the reading of a co-oximeter unreliable.
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2679_Ch27_433-452.indd 448 07/02/13 4:46 PM

STUDENT: DATE:
BENCH-TOP ABG ANALYZER MAINTENANCE
PERFORMANCE LEVEL
PERFORMANCE RATING
Performance Level:
NA = Not applicable
Performance Rating:
EQUIPMENT PREPARATION
1. Performs daily maintenance:
A. Checks the fluid level of pH and flush
B. Checks the cal and slope tanks and gas flow
C. Checks the levels of humidifiers
D. Empties the waste bottle
E. Inserts a daily cleaner
2. Calibrates the blood gas analyzer:
A. Obtains the correct barometric pressure
B. Performs a two-point calibration going from low-high buffer (pH) then from low gas–high gas (PCO2 and PO2)
C. Using the following formula, calculates correct gas values: (PB – 47) × % gas in tank = mm Hg to be calibrated
3. Performs electrode maintenance (if applicable):
A. Every 2 weeks, replaces the pH reference PCO2 and PO2 membranes, if applicable:
1) Remembranes according to the procedure manual, if applicable; fills with an electrolyte solution; cleans out the chamber and
places the electrode back into the machine
2) PCO2: removes from the machine, empties the solution, and removes the membrane; cleans and remembranes following the
procedure manual for the machine; fills with an electrolyte solution; cleans out the electrode chamber and places the electrode
back into the machine
3) PO2 electrodes: removes from the machine, empties the solution, and removes the membrane; cleans and remembranes
according to the procedure manual for the machine; fills with an electrolyte solution
4) Cleans out the electrode chamber and places the electrode back into the machine
B. On most analyzers, replaces the electrode block annually
4. Calibrates the machine prior to analyzing the blood gas sample
5. Performs quality controls:
A. Verifies lot numbers and expected ranges
B. Inserts three levels of quality control (acidosis, normal, alkalosis)
C. Corrects any errors and reruns if necessary
FOLLOW-UP
6. Documents preventive maintenance procedures
7. Produces Levey-Jennings plots:
A. Able to identify Levey-Jennings plots that are in control, random error, shift, trend, and out of control
2679_Ch27_433-452.indd 449 07/02/13 4:46 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch27_433-452.indd 450 07/02/13 4:46 PM


STUDENT: DATE:
ABG ANALYSIS
PERFORMANCE LEVEL
PERFORMANCE RATING
Performance Level:
NA = Not applicable
Performance Rating:
EQUIPMENT PREPARATION
1. Calibrates the bench-top analyzer prior to analyzing the blood gas sample
2. Confirms that the bench-top analyzer and its electrodes are operating properly
3. Identifies the specimen and confirms all relevant information provided on the request slip
4. Notes the time at which the sample was obtained; verifies that sample is run within 15 minutes of the ABG puncture (if the sample has
been placed in an iced slush, analyzes it within 60 minutes of the ABG puncture; does not use iced samples with POCT cartridges)
5. Inspects the sample for obvious signs of preanalytical error (i.e., air bubbles, gross dilution, clotting, air exposure)
6. Mixes the sample
7. Uncaps the syringe and expels and discards two to three drops of blood from the syringe tip
8. Introduces the sample manually or by automatic aspiration into the ABG analyzer; if using a POCT cartridge, introduces the sample to
the fill line and closes the sample well cover; places the cartridge into the POCT analyzer
9. Confirms the readings
10. Removes the syringe or cartridge and clears the system
FOLLOW-UP
12. Transmit the results
13. Correctly analyzes and interprets the acid-base balance
14. Contacts the responsible clinician and/or physician with any critical values
2679_Ch27_433-452.indd 451 07/02/13 4:46 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch27_433-452.indd 452 07/02/13 4:46 PM

CHAPTER Blood Gas
Interpretation
and Calculations
INTRODUCTION The respiratory care practitioner (RCP) must not only be proficient in obtaining blood gas
samples but also must be able to interpret the results in order to make recommendations
and modify therapeutic interventions related to acid–base, ventilation, and oxygenation
status. Many calculations and formulas assist in estimating the adequacy of physiological
indexes or approximating needed changes in oxygen or ventilator parameters.
Calculations also are helpful in verifying the accuracy of derived values from blood
gas sampling measurements.1,2
OBJECTIVES 1. Identify and correct preanalytical errors affecting blood gas results, including inadvertent
Upon completion of this venous sampling, air bubbles in the sample, excess heparinization, and delayed sample
chapter, you will be able to: analysis.
2. Interpret arterial blood gas analysis results and make recommendations for oxygen therapy
based on the interpretations.
3. Calculate Pao2, P(A – a)Do2, arterial:alveolar oxygen tension (a:A) ratio, Cao2, Cvo2, and
C(a – v)o2, Vo2, and cardiac output using the Fick equation, acid:base ratios, pH, Hco3–,
and total carbon dioxide.
4. Estimate the Fio2 needed to obtain a desired Pao2.
5. Using a graphic representation of the oxyhemoglobin dissociation curve, determine Sao2,
Cao2, Pao2, and P-50.
KEY TERMS
acidosis exacerbation hyperoxia preanalytical
alkalosis hypercarbia logarithm superimposed
453
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Exercises
F Arterial blood gas results F Logs
F Computer runs F Ruler
F Computer tutorials
F Logarithm table or calculator with log
function
EXERCISE 28.1 INTERPRETATION OF ARTERIAL BLOOD GAS VALUES
Review normal arterial and Perform the following steps to interpret arterial blood gas sample results:
venous values (Table 28.1). 1. Obtain blood gas analysis results to interpret. Your instructor will provide you with one or
more of the following:
Blood gas log records
Computer runs of blood gas results
Blood gas record slips
Computerized practice and drill tutorials
2. Consider the following as abnormalities:
pH
<7.35: acidotic
>7.45: alkalotic
Pco2—Respiratory component
>45 mm Hg: acidotic (hypoventilation)
<35 mm Hg: alkalotic (hyperventilation)
Hco3– —Metabolic component
<22 mEq/L: acidotic
>26 mEq/L: alkalotic
BE—Metabolic component
<–2: acidotic
>+2: alkalotic
Po2
<80 mm Hg mild hypoxemia
<60 mm Hg moderate hypoxemia
<40 mm Hg severe hypoxemia
>100 mm Hg hyperoxia
A. You must consider the correlation with oxygen therapy (uncorrected, corrected, or
overcorrected).
B. You must consider the age of patient:
i. Newborn normal Pao2 is 40 to 70 mm Hg.
ii. Over 60 years old, Pao2 may decrease approximately 1 mm Hg per year.
iii. Any Pao2 below 60 mm Hg is abnormal.
Table 28.1 Normal Blood Gas

Arterial Venous
Values
pH: 7.40 (7.35–7.45) pH: 7.34–7.36
PaCO2: 40 (35–45) mm Hg PvCO2: 46–48 mm Hg
PaO2: 100 (80–100) mm Hg PvO2: 40 (37–43) mm Hg
SaO2: 97% SvO2: 70%–75%
HCO3_: 22–26 mEq/L
BE: ±2
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C H A P T E R 28 | B LO O D G A S I N T E R P R E TAT I O N AND C ALC ULATIONS • 455
3. Interpret the acid:base status:
A. Look at the pH and decide whether it is acidotic, alkalotic, or normal. If normal, is it on
the acidotic or alkalotic side of 7.40? Mark your decision next to the pH value.
B. Look at the Paco2 and determine whether it is normal, acidotic, or alkalotic.
C. Look at Hco3–/BE. Determine whether it is normal, acidotic, or alkalotic.
D. Determine whether the primary condition is respiratory or metabolic. See which
component (CO2 or base) matches the pH (same direction, alkalotic, or acidotic).
E. If you have concluded that a metabolic acidosis is present then calculate the anion gap.
–
Anion Gap = (Na+) – (Cl + Hco3–)
This calculation will determine if the acid:base status is caused from the accumulation
of fixed acids in the blood or an excessive loss of Hco3–. The normal anion gap range
is 9 to 14 mEq/L. A high anion gap indicates that the patient is suffering from the
accumulation of fixed acids in the blood while a normal or low anion gap indicates
that the patient has had an excessive loss of Hco3–-. Because treatment of these two
types of metabolic acidosis is very different, calculating the anion gap can provide
useful information that will lead to more effective medical treatment.
F. Determine how much compensation is occurring:
i. Look at the nonprimary component to see if it is normal. If normal, this is an acute
uncompensated condition.
ii. If the nonprimary component is abnormal, determine in which direction it is
occurring. If it is in the opposite direction of the primary problem, compensation
has begun. This is a chronic, partially compensated condition.
iii. If the pH is normal, compensation is complete.
iv. If the nonprimary component is abnormal in the same direction as the primary
component, it is a mixed condition.
4. You must consider the patient history, diagnosis, and treatment, if known, to fully
interpret. There may be an acute problem superimposed on a chronic problem—for
example, a COPD patient with chronic hypercarbia placed on a mechanical ventilator
or having an acute exacerbation. The following series of blood gases are given as an
illustration in Table 28.2.
5. Oxygenation status:
A. Look at the Po2 and determine whether it is normal, hypoxemic, or hyperoxic.
B. Look at the oxygen therapy being given, if any, and determine whether the Po2 is
uncorrected, corrected, or overcorrected.
C. Remember to consider the age of the patient.
D. Look at the hemoglobin, So2, oxygen content, and vital signs to determine whether there
are any indications of tissue hypoxia.
6. Compare the results with the patient’s previous results, if available, and the clinical
condition.
7. Consider any possible sources of error, such as excess heparin, air bubbles, inadvertent
venous sample, improperly iced sample or delayed analysis, or analyzer temperature not
at 37°C.
NOTE: There is a lack of a scientific basis for correction of blood gases for changes in patient
body temperature. Appropriate clinical interpretation is better accomplished when temperature
correction is avoided.1
Table 28.2 Sample Blood Gas

Normal State On Admission After Ventilation
Values
pH 7.37 7.25 7.47
PCO2 55 70 45
HCO3_ 31 30 32
BE +4 +5 +3
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EXERCISE 28.2 CALCULATION OF OXYGENATION PARAMETERS

EXERCISE 28.2.1 OX YGEN DISSOC IAT I O N C U R V E
The following problems should be answered using the oxygen dissociation curve in Figure 28.1.
Do not “calculate” answers. Use your ruler to line up the y and x axes on the graph to determine
the following parameters. Record your answers on your laboratory report.
1. With the curve in a normal position, for the following values of Po2, determine the Sao2.
A. 60 mm Hg
B. 50 mm Hg
C. 90 mm Hg
D. 40 mm Hg
2. With the curve in the normal position, for the following values of Po2, determine the Cao2.
A. 60 mm Hg
B. 20 mm Hg
C. 90 mm Hg
D. 40 mm Hg
3. For the following P-50 values, determine whether the curve has shifted left or right.
A. 20 mm Hg
B. 30 mm Hg
4. For the shifted curves shown in Figure 28.2, determine the P-50 value by lining up your ruler
with an So2 value of 50%, intersecting the curve, and then drawing a perpendicular line
down to the corresponding Po2 value. For the curves shifted to the left and to the right,
record your answers on your laboratory report.
Percent saturation hemoglobin
O2 content mL/100 (vol %)

2
Figure 28.1. The oxyhemoglobin dissociation curve. PO2 (mm Hg)
pH
% Hemoglobin saturation
DPG pH
Temp DPG
Temp
Normal
Figure 28.2. The shifted oxyhemoglobin dissociation

curve. PO2 (mm Hg)
2679_Ch28_453-466.indd 456 07/02/13 4:46 PM

EXER C ISE 28 .2 .2 C AL C UL AT I O N O F A LV E O LA R A I R E Q U AT I O N , A LV E O LA R A R T E R I A L
OXYGEN G R A D I E N T, A N D A R T E R I A L:A LV E O LA R O X Y G E N R AT I O
You can use the following equation to determine the Pao2. Because Pao2 should approximate
Pao2, the formula is helpful in determining the maximum possible Pao2 for a given Fio2. This is
useful in evaluating a possible preanalytical error from air bubble inclusion.
Pao2 = [Fio2 (Pb – 47)] – (Paco2 × 1.25)
From this calculation, the P(A – a)Do2 can then be determined by using the formula:
Pao2 – Pao2 = P(A – a)Do2
This formula also can be used to estimate the degree of hypoxemia or the degree of physiological
shunt.2
The arterial:alveolar oxygen ratio is an indicator of the efficiency of oxygen diffusion. A low a:A
ratio reflects ventilation perfusion (V/Q) mismatches, diffusion defects, or shunts.3 The a:A ratio
is determined by the following formula:
Pao2/Pao2 = a:A ratio
1. For each of the following, calculate the Pao2, the P(A – a)Do2, and the a:A ratio. Show your
work and record your answers on your laboratory report.
A. Fio2 = 0.21, Pb = 760 mm Hg, Paco2 = 40 mm Hg, Pao2 = 100 mm Hg
B. Fio2 = 1.00, Pb = 760 mm Hg, Paco2 = 40 mm Hg, Pao2 = 650 mm Hg
C. Fio2 = 0.50, Pb = 750 mm Hg, Paco2 = 50 mm Hg, Pao2 = 60 mm Hg
D. Fio2 = 0.21, Pb = 755 mm Hg, Paco2 = 20 mm Hg, Pao2 = 110 mm Hg
2. Calculate the highest possible values of Pao2 for the following values of Paco2 for a patient’s
breathing room air at sea level.
A. Paco2 = 25 mm Hg
B. Paco2 = 15 mm Hg
C. Paco2 = 30 mm Hg
D. Paco2 = 50 mm Hg
E. Paco2 = 70 mm Hg
EXER C ISE 28 .2 .3 F I O 2 N EE D E D FO R A D E S I R E D P A O 2
This calculation is useful For the following blood gas examples, calculate the Fio2 needed. Show your work and record
to estimate the FIO2 needed your answers on your laboratory report.
for a desired PaO2 in a Step 1: Calculate the Pao2 as in the preceding exercises.
patient with hypoxemia Step 2: Calculate the a:A ratio as in the preceding exercises.
caused by V/Q mismatch Step 3: Calculate the Pao2 needed.
or hypoventilation. It is
Pao2 needed = Pao2 desired/a:A ratio
less reliable in severe
intrapulmonary shunts.4 Step 4: Calculate the Fio2 needed.
Fio2 needed = Pao2 needed + (Paco2 × 1.25 )/Pb – 47
1. Pao2 = 40 mm Hg, Paco2 = 30 mm Hg, Fio2 = 0.21,
Pb = 760 mm Hg, Desired Pao2 = 80 mm Hg
2. Pao2 = 50 mm Hg, Paco2 = 60 mm Hg, Fio2 = 0.25
Pb = 750 mm, Desired Pao2 = 60 mm Hg
3. Pao2 = 500 mm Hg, Paco2 = 40 mm Hg, Fio2 = 1.0
Pb = 765 mm, Desired Pao2 = 90 mm Hg
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EXERCISE 2 8 .2 .4 ARTERIAL OXYGEN C O N T E N T, V E N O U S O X Y G E N C O N T E N T, A R T E R IA L

V EN OUS OX YGEN D I FFE R E N C E , O X Y G E N C O N S U MP T I O N , A N D C A R D I A C
OUTPUT US IN G TH E FI C K E Q U AT I O N
Cao2 = (Pao2 × 0.003) + (Hb × 1.39) Sao2
Cvo2 = (Pvo2 × 0.003) + (Hb × 1.39) Svo2
C(a – v)o2 = Cao2 – Cvo2
Vo2 = C(a – v)o2 × (cardiac output) × 10
For each of the following, perform the above calculations. Show your work and record your an-
swers on your laboratory report.
1. Arterial Mixed Venous
pH 7.25 7.22
Pco2 55 mm Hg 62 mm Hg
Pao2 60 mm Hg 30 mm Hg
Sao2 88% 65%
Hb 18 g/100 mL
Cardiac output 4.0 L/minute
Fio2 0.21
2. Arterial Mixed Venous
pH 7.35 7.32
Pco2 65 mm Hg 72 mm Hg
Pao2 50 mm Hg 20 mm Hg
Sao2 85% 60%
Hb 18 g/100 mL
Vo2 180 mL/minute
Fio2 0.24
EXERCISE 28.3 ACID–BASE CALCULATIONS
Use the following formulas to calculate acid–base parameters:
Base:acid ratio = Hco3–

Paco2 × 0.03
pH = 6.1 + log
[ Hco3–
Paco2 × 0.03 ]
Total co2 mM/L = (Paco2 × 0.03) + Hco3–
For each of the following, calculate the base:acid ratio, pH, and total CO2. Show your work and
record your answers on your laboratory report.
1. Hco3– = 20 mEq/L, Pco2 = 37 mm Hg
2. Hco3– = 32 mEq/L, Pco2 = 42 mm Hg
3. Hco3– = 35 mEq/L, Pco2 = 55 mm Hg
4. Hco3– = 17 mEq/L, Pco2 = 28 mm Hg
For the following, calculate the Hco3–. Show all work and record your answers on your labora-
tory report.
5. pH = 7.35 , Pco2 = 60
6. pH = 7.45, Pco2 = 45
7. pH = 7.15, Pco2 = 20
8. pH = 7.55, Pco2 = 20
RE F E RE N CE S
1. Shapiro, BA, Peruzzi, WT, and Kozelowski-Templin, R: Clinical Application of Blood Gases. Mosby, St. Louis, 1994, p. 231.
2. American Association for Respiratory Care: AARC clinical practice guideline: In vitro pH and blood gas analysis and hemoximetry. Respir
Care 46(5):498–505, 2001.
3. Chang, DW: Respiratory Care Calculations, ed. 2. Delmar, Albany, 1999, p. 18.
4. Chang, DW: Respiratory Care Calculations, ed. 2. Delmar, Albany, 1999, p. 89.
2679_Ch28_453-466.indd 458 07/02/13 4:46 PM

Laboratory Report
CHAPTER 28: BLOOD GAS INTERPRETATION AND CALCULATIONS
Name: Date:
Data Collection
EXERCISE 28.2 Calculation of Oxygenation Parameters
E X E R C IS E 28 . 2. 1 O X Y G E N D IS SOCIATION CURVE
1. A. 60 mm Hg = ____________________________________________
B. 50 mm Hg = ___________________________________________
C. 90 mm Hg = ____________________________________________
D. 40 mm Hg = ____________________________________________
2. A. 60 mm Hg = ____________________________________________
B. 20 mm Hg = ___________________________________________
C. 90 mm Hg = ____________________________________________
D. 40 mm Hg = ____________________________________________
3. For the following P-50 values, determine whether the curve has shifted left or right:
A. 20 mm Hg = ____________________________________________
B. 30 mm Hg = ___________________________________________
4. For the curve shifted to the left, P-50 = _________________________
For the curve shifted to the right, P-50 = ________________________
E X E R C IS E 28 . 2. 2 C A L C U L AT ION OF P A O 2 , P(A – a)D O 2 , a: A RATIO
1. Calculation of the PAO2, the P(A – a)DO2, and the a:A ratio. (See text.) Show your work.
A. PAO2 = ________________________________________________
P(A – a)DO2 = ___________________________________________
a:A ratio = _____________________________________________
B. PAO2 = ________________________________________________
P(A – a)DO2 = ___________________________________________
a:A ratio = _____________________________________________
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C. PAO2 = ________________________________________________
P(A – a)DO2 = ___________________________________________
a:A ratio = _____________________________________________
D. PAO2 = ________________________________________________
P(A – a)DO2 = ___________________________________________
a:A ratio = _____________________________________________
2. Calculation of PaO2 (see text):
A. PaO2 = ________________________________________________
B. PaO2 = ________________________________________________
C. PaO2 = ________________________________________________
D. PaO2 = ________________________________________________
E. PaO2 = ________________________________________________
E XE RCI SE 2 8 .2 . 3 F I O 2 N E E D E D F O R A D E S IR E D Pa O 2
Show all work for all steps.
1. PAO2 = __________________________________________________
a:A ratio = _______________________________________________
PAO2 needed = ____________________________________________
FIO2 needed = _____________________________________________
2. PAO2 = __________________________________________________
a:A ratio = _______________________________________________
PAO2 needed = ____________________________________________
FIO2 needed = _____________________________________________
3. PAO2 = __________________________________________________
a:A ratio = _______________________________________________
PAO2 needed = ____________________________________________
FIO2 needed = _____________________________________________
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E X E R C IS E 28 . 2. 4 Ca O 2 , C v O 2 , C (a – v ) O 2 , V O 2 , AN D CARDIAC OUTPUT (C. O. ) USIN G THE F ICK EQUATI ON
1. CaO2 = __________________________________________________
CvO2 = __________________________________________________
C(a – v)O2 = ______________________________________________
VO2 = ___________________________________________________
2. CaO2 = __________________________________________________
CvO2 = __________________________________________________
C(a – v)O2 = ______________________________________________
C.O. = ___________________________________________________
EXERCISE 28.3 Acid–Base Calculations
1. Base:acid ratio = __________________________________________
pH = ____________________________________________________
Total CO2 = _______________________________________________
2. Base:acid ratio = __________________________________________
pH = ____________________________________________________
Total CO2 = _______________________________________________
3. Base:acid ratio = __________________________________________
pH = ____________________________________________________
Total CO2 = _______________________________________________
4. Base:acid ratio = __________________________________________
pH = ____________________________________________________
Total CO2 = _______________________________________________
5. HCO3– = __________________________________________________
6. HCO3– = __________________________________________________
7. HCO3– = __________________________________________________
8. HCO3– = __________________________________________________
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1. Mr. Sample is a 33-year-old nonsmoking healthy man who has volunteered to serve as a control in a research study.
After performing a positive Allen’s test, an arterial blood gas sample is drawn on room air as part of the study. The
blood gas kit used did not contain a preheparinized syringe. Liquid heparin was used to heparinize the syringe before
sampling.
A. If the following blood gas result was obtained, what type of preanalytical error would you suspect, if any? What
action would you take at this time, if any?
pH = 7.35, Paco2 = 46 mm Hg, Pao2 = 45 mm Hg, Sao2 = 77%, Hco3– = 23 mEq/L
B. If the following blood gas result was obtained, what type of preanalytical error would you suspect, if any? What
action would you take at this time, if any?
pH = 7.50, Paco2 = 25 mm Hg, Pao2 = 150 mm Hg, Sao2 = 100%, Hco3_ = 26 mEq/L
2. Miss Smith is a 28-year-old female brought to the emergency department by paramedics after she was found in her
home with a decreased level of consciousness and confusion. She is a known diabetic. The patient was placed on a
simple mask in the ambulance. An arterial blood gas is ordered and drawn using an arterial blood gas kit prepared
with liquid heparin.
A. Interpret and explain the following results:
pH = 7.20 , Na+ = 140 mEq/L, Paco2 = 23 mm Hg, K+ = 4.3 mEq/L, Pao2 = 64 mm Hg, Cl– = 105 mEq/L,
Sao2 = 94 %, Hco3– = 9 mEq/L
B. If excess heparin remained in the syringe during sampling, how would it affect the pH and Paco2 values obtained?
C. If analysis of the sample were delayed by 1 hour without icing the sample, how would the pH, Paco2, and Pao2
be changed? Why?
3. Mr. Khan is a 65-year-old with a history of atrial fibrillation. He takes Coumadin. He complained of increasing short-
ness of breath and was transported to the emergency department by the paramedics with a nonrebreathing mask in
place. The patient is lethargic. You are called to draw an arterial blood gas.
A. What factors might you consider while performing the puncture?
B. Interpret and explain the following results:
pH = 7.30, Paco2 = 68 mm Hg, Pao2 = 122 mm Hg, Hco3– = 32 m Eq/L
C. After calculating the Fio2 needed for a desired Pao2, what recommendations would you make concerning an
appropriate oxygen delivery device?
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4. A 47-year-old male with a history of peptic ulcer disease is admitted to the hospital with abdominal pain and vomiting
for the past week. He complains of vomiting for 2 days. An arterial blood gas is drawn on room air and reveals the
following values:
pH = 7.49, Paco2 = 42 mm Hg, Paco2 = 70 mm Hg, Hco3– = 36 mEq/L
A. Interpret the results.
B. Explain the cause(s) for these results.
C. What specific recommendations would you make at this time?
5. A young man is brought to the emergency department by his friends. He became comatose at a party. Drug parapher-
nalia is found in his pockets. The patient has shallow respirations with a respiratory rate of 6 breaths/min. An arterial
blood gas is drawn on room air and reveals the following values:
pH = 7.19, Paco2 = 70 mm Hg, Pao2 = 45 mm Hg, Hco3– = 25 mEq/L
6. A code blue is called for a patient in the intensive care unit. CPR is initiated and manual ventilation by bag-valve mask
is given. During the resuscitation effort, the patient is orally intubated and manual ventilation is continued with the en-
dotracheal tube in place. After successful cardiopulmonary resuscitation, the following blood gas results were obtained
while the patient was still being manually ventilated:
pH = 7.10, Paco2 = 50 mm Hg, Pao2 = 55 mm Hg, Hco3– = 15 m Eq/L
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STUDENT: DATE:
ARTERIAL BLOOD GAS INTERPRETATION
PERFORMANCE LEVEL
PERFORMANCE RATING
Performance Level:
NA = Not applicable
Performance Rating:
1. Obtains and analyzes an arterial blood gas sample

2. Evaluates the pH
3. Evaluates the PaCO2
4. Evaluates the HCO3–
5. Evaluates the BE
6. Interprets the acid–base status
7. If the acid–base status is abnormal, correctly identifies if it is a metabolic or respiratory disturbance
8. Determines if any compensation is present
9. Evaluates the PaO2
10. Evaluates the SaO2
11. Interprets the patient’s oxygenation status
12. Uses P-50 to determine if there is a shift in the oxygen dissociation curve
13. Determines CaO2 using the oxygen dissociation curve
14. Calculates P(A – a)DO2
15. Calculates the FIO2 needed for the desired PaO2
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PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
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CHAPTER Basic Chest X-ray
Interpretation
INTRODUCTION Radiologists and pulmonologists develop x-ray interpretation skills over the course of
several years and hundreds of films. Although respiratory care practitioners (RCPs) are
not expected to achieve this level of expertise, the ability to identify a normal chest x-ray
and common cardiopulmonary abnormalities should be a part of the basic skills an
advanced-level RCP can perform. In a critical situation, knowledge of x-ray interpretation
can be crucial to patient care. In conjunction with other patient assessment techniques,
radiography can confirm atelectasis, pneumothorax, or endotracheal tube placement.
Recognition of frequently encountered findings such as hyperinflation, infiltrates,
pulmonary edema, and pneumonia is an asset to the RCP and improves patient care.
The x-ray film is similar to a photographic negative. A film, or cassette, is placed next to
the patient. Roentgen rays are emitted by the x-ray machine, pass through the patient,
and become absorbed proportionately to the density of the tissue the rays pass through.
Thus, objects that are the densest absorb the x-rays and the film is not altered
photographically. These objects are called radiopaque, or radiodense, and appear white
to gray depending on the density. Objects that absorb fewer rays are called radiolucent.
Air, which allows the rays to pass through, appears black.1
The RCP must remember that the image created is two-dimensional and the position
and distance of the patient relative to the x-ray machine are important. Chest x-rays
can be taken in several positions and the view describes the path or direction in which
the ray passes through the patient onto the cassette. The most common view is the
posteroanterior (PA) in an ambulatory patient. The anteroposterior (AP) is the usual view
of a portable film in a more critically ill patient. The lateral, lordotic (used to expose the
upper lobes), and decubitus projections are also used.2
The proficient interpretation of x-rays by RCPs takes much practice, but a systematic
approach can aid the learning process.
Other techniques can also determine lung abnormalities. Transillumination of an infant

chest may help identify pneumothorax. Ventilation perfusion scans may assist in the
diagnosis of pulmonary emboli. The chest x-ray is limited by its two-dimensional nature.
Patient complaints and symptomatology sometimes do not correlate with the chest x-ray
findings. In these situations, advanced techniques such as computerized tomography
(CT) scans or magnetic resonance imaging (MRI) may define a pulmonary abnormality
that might or might not be identifiable on routine chest x-ray. The interpretation of these
techniques is well beyond the scope of the RCP.
467
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OBJECTIVES 1. Differentiate between radiopaque and radiolucent structures.

Upon completion of this 2. Given a chest x-ray, verify the patient identity, film projection, position, and quality of the film.
3. Identify the major organs and anatomic landmarks on adult and infant chest x-ray films,
including the aortic knob and heart shadow, costophrenic angles, hemidiaphragms, spinal
column, ribs and rib angles, sternum, clavicles, hila, trachea and bifurcation (carina), air
bronchogram, stomach bubble, and breast shadows.
4. Confirm the position of an endotracheal tube.
5. Identify the placement of chest tubes and pulmonary artery catheters.
6. Locate the following abnormalities on a chest x-ray: atelectasis, pneumothorax, hyperinflation,
pleural effusion, large masses, infiltrates, pneumonia, hilar adenopathy, cavitary lesions,
respiratory distress syndrome (RDS), epiglottitis, croup, and bronchopulmonary dysplasia (BPD).
7. Differentiate chest deformities from normal chest structure.
KEY TERMS
adenopathy costophrenic lordotic reticulogranular
air bronchogram dysplasia mass tomography
bifurcation exudate nodule tortuous
blunted hyperlucent opacification transillumination
cardiomegaly infiltrates radiodense transudate
caseation interstitium radiolucent
Exercises
F Abnormal x-rays provided by your instructor F Epiglottitis
F Chest x-rays of the following: F Normal infant chest film
F AP view F Respiratory distress syndrome
F Atelectasis F Pneumonia—lobar and diffuse
F Bronchiectasis F Pneumothorax
F Endotracheal tube in proper placement F Pulmonary fibrosis
F Hyperinflation F Trached patient
F Improperly placed endotracheal tube F Tuberculosis
F Intubated patient F Grease pencil
F Kyphoscoliosis F Measuring tape
F Lateral and decubitus views F Spare fluorescent bulbs
F Lordotic view F X-ray view boxes
F Normal PA and lateral views
F Lung cancer
F Pediatric chest films
F Bronchopulmonary dysplasia
F Croup
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C H A P T E R 29 | B A S I C C H E S T X - R AY INTER P R ETATION • 469
EXERCISE 29.1 IDENTIFICATION OF POSITIONS
Identify the position of the film in Figures 29.1 through 29.4 and label each one. Record the
answers on your laboratory report.
Figure 29.1. Film A. Figure 29.2. Film B.

Decubitus
PA view
Figure 29.3. Film C.
Lateral view
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Figure 29.4. Film D.
Ap view or lordotic view
EXERCISE 29.2 IDENTIFICATION OF MAJOR ORGANS AND LANDMARKS
You need a systematic 1. Obtain a normal PA chest x-ray, insert it onto the view box, and turn on the view box.
approach when viewing a 2. Verify that you have the correct patient’s film.
chest film and the following
NOTE: In the laboratory setting, for reasons of patient confidentiality, you should remove or
method is a useful guide. It
mask the patient name.
is helpful to use your index
finger to trace along the 3. Place the film so that it seems as if the patient is facing you. This is the standard method of
structure to help identify and viewing.3 Look for the lead marker.
delineate the object you are 4. Observe the entire film for symmetry:
viewing. A. Identify the clavicles, scapulae, and ribs.
B. Identify the spinal column. Is it midline?
C. Identify the lungs, right and left.
D. Are there breast shadows?
E. Locate the gastric air bubble.
F. Observe the film to ensure that none of the peripheral structures were “clipped,” or
incompletely shown, because of patient positioning.
5. Observe the film for the quality of the exposure. Is the overall quality too dark or too
white? The thoracic spine should be just visible on a routine chest x-ray.4
6. Starting in the upper left side, trace your finger along the edge of the lungs down to the
edge where the lung meets the diaphragm. This is the costophrenic angle. Is it sharp or
blurred (possible fluid), or is it less sharp (blunted)?
7. Note the rib level of the hemidiaphragms. Chest x-rays are taken at the peak of inspiration,
and the diaphragms should be at the level of rib 8 or rib 9. This helps the radiologist
determine whether the film is of good or poor inspiratory quality.
8. Trace the outline of each rib, starting from the sternum and moving outward. Do they go to
the edge of the film? Are they continuous or interrupted (indicating a fracture)? Note the
angle of the ribs anteriorly. Are they horizontal? Estimate the angle.
9. Observing the center of the film, observe the trachea’s position. The trachea appears as a
column of air. Is it midline? Follow the trachea to the point of bifurcation.
10. Identify the carina and the mainstem bronchi (the air bronchogram). Count the level of
vertebrae and intercostal spaces corresponding to the carina. The carina should be at
approximately T5 and between the second and third intercostal space.
11. Examine the hila for size and position. Because of anatomy, the left hilum normally appears
higher than the right. The radiopaque image represents the pulmonary vasculature. Trace
the lines out. These are the “lung markings” and also represent blood vessels, not airways.
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12. In the center of the film, identify the aortic knob and the heart shadow. The cardiothoracic
ratio is used to express heart size. If the shadow occupies more than 50%, it is considered
abnormally enlarged.5 Approximate how much of the film is occupied by the heart shadow,
as shown in Figure 29.5, and record it on your laboratory report.
NOTE: On AP films, the heart will appear larger than its actual size. Therefore, this projection
should not be used to measure heart size.
13. Identify the following structures on Figure 29.6 and record them on your laboratory report.
Rib Rib= D
Carina Carina=K
Clavicle Clavicle=B
Scapula Scapula=C
Lung field Lung field= P
Left heart border (apex) Left heart border(apex)= F
Right heart border Right heart border=E
Hila Hila= I
Larynx Larynx/spinous process area= H
Trachea
Trachea= A
Carina (tracheal bifurcation)
Left hemidiaphragm
Left hemidiaphragm=L
Right hemidiaphragm
Right hemidiaphragm/lung parenchyma=J
Costophrenic angles Costophrenic angles= G
Aortic knob Aortic knob=O
Gastric bubble Gastric bubble= N
Gastric air=M
Extrathoracic soft tissue=p
Figure 29.5. Measurement of heart size. Figure 29.6. Label the x-ray, naming the anatomic landmarks and other
characteristics.
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EXERCISE 29.3 HYPERINFLATION
1. Obtain an x-ray film already interpreted as hyperinflation, as shown in Figure 29.7, and
compare it with the normal film used in Exercise 29.2.
2. Using the technique practiced in the previous exercise, observe and identify the following.
Record them on your laboratory report.
Film ID, patient demographics if known
Projection used
Patient position
Flattening of the hemidiaphragms: note the level of the ribs; location of the diaphragms
at the level of rib 11 is an indicator of hyperinflation
Horizontal rib margins
Increased intercostal spaces
Areas of hyperlucency with decreased lung markings
Lung size: compare the size of the lungs
Increased AP diameter on a lateral film
PA view
lateral deductibus
Figure 29.7. X-ray typical of emphysema. (From Wilkins, RF, and Dexter, JR: Respiratory Disease: Principles of Patient Care. FA Davis, Philadelphia, 1993, p. 48,
with permission.)
Image is underexposed
EXERCISE 29.4 PNEUMOTHORAX
1. Obtain a film with a confirmed pneumothorax, as shown in Figure 29.8, and compare it with
the normal film used in Exercise 29.2.
2. Using the technique practiced in the previous exercise, observe and identify the following.
Record them on your laboratory report.
Film ID, patient demographics (if available)
Projection used
Patient position
Tracheal or mediastinal shift indicating a tension pneumothorax: note that not all films
display a shift
Area of darker region without lung markings
Line of demarcation indicating the edge of the collapsed lung
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Figure 29.8. Pneumothorax.
EXERCISE 29.5 ATELECTASIS OR CONSOLIDATION
1. Obtain a film with a confirmed atelectasis or consolidated lung, as shown in Figure 29.9, and
compare it with the normal film used in Exercise 29.2.
2. Using the technique practiced in Exercise 29.2, observe and identify the following. Record
them on your laboratory report.
Projection used
Patient position
Hemidiaphragm positions (relative to normal and relative to each other)
Area of radiopaque image in an area where it should be radiolucent
Mediastinal shift (if any)
Decreased lung volumes
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Figure 29.9. Atelectasis or consolidation.
EXERCISE 29.6 ENDOTRACHEAL TUBE POSITION
1. Obtain a film with a confirmed endotracheal tube, as shown in Figure 29.10, and compare it
with the normal film used in Exercise 29.2.
2. Using the technique practiced in Exercise 29.2, observe and identify the following. Record
Projection used
Patient position
The radiopaque line of the endotracheal tube
The radiopaque line of the naso- or orogastric tube
Aortic knob
The level of carina
Tip of the endotracheal tube (at what level?): state three identifying landmarks
3. Once you have identified the structures, identify the following. Record the answers on your
laboratory report.
A. Count the ribs. At the level of what rib or intercostal space anteriorly is the tube?
B. Count the vertebrae. At the level of what vertebra is the tube?
C. Approximately how far is the tip of the endotracheal tube above the carina?
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Figure 29.10. Endotracheal tube

in position.
EXERCISE 29.7 KYPHOSCOLIOSIS
1. Obtain a film of kyphoscoliosis (Fig. 29.11).

2. Using the technique practiced in the previous exercises, compare the abnormalities to a
normal chest film. Record them on your laboratory report.
Figure 29.11. Kyphoscoliosis.
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EXERCISE 29.8 INFANT AND PEDIATRIC FILMS
1. Obtain a normal infant film (Fig. 29.12). Using the technique practiced in the previous
exercises, observe the film and compare it with a normal adult chest x-ray. Record your
findings on your laboratory report.
2. Obtain films of the following:
Steeple sign in croup (Fig. 29.13)
Thumb sign in epiglottitis (Fig. 29.14)
Respiratory distress syndrome (RDS) (Fig. 29.15)
Bronchopulmonary dysplasia (BPD) (Fig. 29.16)
3. Using the technique practiced in the previous exercises, compare the abnormalities to a
normal chest film. Record them on your laboratory report.
Figure 29.12. (A) and (B): Normal infant chest films.
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Figure 29.13. Steeple sign in croup. (From Wilkins, RF, and Dexter, JR: Respiratory Disease: Principles of Patient Care.
Figure 29.14. Thumb signs in epiglottitis. (From Wilkins, RF, and Dexter, JR: Figure 29.15. Infant respiratory distress syndrome. (From Wilkins, RF, and
Respiratory Disease: Principles of Patient Care. FA Davis, Philadelphia, 1993, Dexter, JR: Respiratory Disease: Principles of Patient Care. FA Davis,
p. 332, with permission.) Philadelphia, 1993, p. 359, with permission.)
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Figure 29.16. Bronchopulmonary dysplasia. (From

Wilkins, RF, and Dexter, JR: Respiratory Disease:
Principles of Patient Care. FA Davis, Philadelphia,
EXERCISE 29.9 OTHER ABNORMAL PATTERNS
1. Your instructor will provide films with other abnormalities. Compare them with the normal
adult film used in Exercise 29.2.
2. Using the technique practiced in the previous exercises, observe and identify the differences
in each film. Record them on your laboratory report.
RE F E RE N CE S
1. Squire, LF, and Novelline, RA: Fundamentals of Radiology, ed. 4. Harvard University Press, Cambridge, 1988, p. 3.
4. Squire, LF, and Novelline, RA: Fundamentals of Radiology, ed. 4. Harvard University Press, Cambridge, 1988, pp. 40–41.
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Laboratory Report
CHAPTER 29: BASIC CHEST X-RAY INTERPRETATION
Name: Date:
Data Collection
EXERCISE 29.1 Identification of Positions
Film A. ______________________________________________________________________________________________________
Film B. ______________________________________________________________________________________________________
Film C. ______________________________________________________________________________________________________
Film D. ______________________________________________________________________________________________________
EXERCISE 29.2 Identification of Major Organs and Landmarks
Cardiothoracic ratio = Heart size / Lung width: ______________________________________________________________________
Label the chest film on Figure 29.6:
A. _________________________________________________________________________________________________________
B. _________________________________________________________________________________________________________
C. _________________________________________________________________________________________________________
D. _________________________________________________________________________________________________________
E. _________________________________________________________________________________________________________
F. _________________________________________________________________________________________________________
G. _________________________________________________________________________________________________________
H. _________________________________________________________________________________________________________
I. _________________________________________________________________________________________________________
J. _________________________________________________________________________________________________________
K. _________________________________________________________________________________________________________
L. _________________________________________________________________________________________________________
M. _________________________________________________________________________________________________________
N. _________________________________________________________________________________________________________
O. _________________________________________________________________________________________________________
P. _________________________________________________________________________________________________________
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EXERCISE 29.3 Hyperinflation
Film ID: _________________________________________________________________
Patient demographics if known: ______________________________________________
Projection used: __________________________________________________________
Patient position: __________________________________________________________
Flattening of the hemidiaphragms: ____________________________________________
Lung expansion to level of rib no.: ____________________________________________
Horizontal rib margins present: ______________________________________________
Increased intercostal spaces: _______________________________________________
Areas of hyperlucency with decreased lung markings: ____________________________
Comparison of lung size: ___________________________________________________
Increased AP diameter on a lateral film: _______________________________________
EXERCISE 29.4 Pneumothorax
Film ID: _________________________________________________________________
Projection used: __________________________________________________________
Mediastinal shift: _________________________________________________________
Area of darker region without lung markings: ___________________________________
Edge of the collapsed lung: _________________________________________________
EXERCISE 29.5 Atelectasis or Consolidation
Film ID: _________________________________________________________________
Projection used: __________________________________________________________
Hemidiaphragm positions: __________________________________________________
Area of radiopaque image in an area where it should be radiolucent: ________________
Mediastinal shift: _________________________________________________________
Decreased lung volumes: ___________________________________________________
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EXERCISE 29.6 Endotracheal Tube Position
Film ID: _________________________________________________________________
Projection used: __________________________________________________________
The radiopaque line of the endotracheal tube:
Level of carina: ___________________________________________________________
Tip of the endotracheal tube (at what level?): state three identifying landmarks: ________
Distance above the carina: _________________________________________________
EXERCISE 29.7 Kyphoscoliosis
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
EXERCISE 29.8 Infant and Pediatric Films
Comparison of Normal Infant Chest X-ray With a Normal Adult Chest X-ray
Film ID: _________________________________________________________________
Patient demographics if known: __________________________________________________________________________________
____________________________________________________________________________________________________________
Steeple Sign in Croup
Film ID: _________________________________________________________________
____________________________________________________________________________________________________________
Thumb Sign in Epiglottitis
Film ID: _________________________________________________________________
____________________________________________________________________________________________________________
Respiratory Distress Syndrome
Film ID: _________________________________________________________________
____________________________________________________________________________________________________________
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Bronchopulmonary Dysplasia
Film ID: _________________________________________________________________
____________________________________________________________________________________________________________
EXERCISE 29.9 Other Abnormal Patterns
1. Abnormality:
Film ID: _______________________________________________________________
Patient demographics if known: ________________________________________________________________________________
Differences observed: ________________________________________________________________________________________
__________________________________________________________________________________________________________
2. Abnormality:
Film ID: _______________________________________________________________
__________________________________________________________________________________________________________
3. Abnormality:
Film ID: _______________________________________________________________
__________________________________________________________________________________________________________
4. Abnormality:
Film ID: _______________________________________________________________
__________________________________________________________________________________________________________
5. Abnormality:
Film ID: _______________________________________________________________
__________________________________________________________________________________________________________
6. Abnormality:
Film ID: _______________________________________________________________
__________________________________________________________________________________________________________
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1. Why would a patient be asked to remove all necklaces, charms, and medals before a chest x-ray?
2. The physician requires a yearly chest x-ray for his or her patient with COPD. Of what benefit is the previous film?
3. Where is the carina normally found on the chest x-ray?
4. Can the chest x-ray determine if the tube is in the esophagus? Why or why not?
5. What factors might make the interpretation of a film difficult?
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6. Given the chest x-rays shown in Figures 29.17 through 29.21, what might the interpretation be?
Figure 29.17 ________________________________________________
Figure 29.17. Unknown film A.
Figure 29.18 ________________________________________________
Figure 29.18. Unknown film B. (From Wilkins, RF, and Dexter, JR: Respiratory Disease: Principles of Patient Care. FA Davis, Philadelphia,
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C H A P T E R 29 | B A S I C C H E S T X - RAY INTER P R ETATION • 485
Figure 29.19 ________________________________________________
Figure 29.19. Unknown film C.
Figure 29.20 ________________________________________________
Figure 29.20. Unknown film D. (From Wilkins, RF,

and Dexter, JR: Respiratory Disease: Principles of
Patient Care. FA Davis, Philadelphia, 1993, p. 212,
with permission.)
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Figure 29.21 ________________________________________________
Figure 29.21. Unknown film E.
7. What are four postprocedural indications for obtaining a chest x-ray?
8. List and describe two important radiographic signs that help the clinician to localize abnormalities within the thorax.
9. What are the four densities that can be seen on an x-ray?
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10. How would a tension pneumothorax look different than a pneumothorax on a chest x-ray?
11. What are the three steps in evaluating a chest x-ray? How do these steps help to evaluate the chest x-ray?
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STUDENT: DATE:
CHEST X-RAY INTERPRETATION

PERFORMANCE LEVEL
PERFORMANCE RATING
Evaluator: Setting:
Performance Level:
NA = Not applicable
Performance Rating:


3. Obtains the chest x-ray film; verifies film identification
4. Inserts the film onto the view box with the correct orientation and turns on the view box light
5. Identifies the projection view of the film and patient position
6. Observes the entire film for symmetry and quality and identifies:
A. Clavicles, scapulae, and ribs
B. Spinal column and thoracic vertebrae; midline visible?
C. Lungs, right and left
D. Costophrenic angles; notes if they are sharp, blurred (possible fluid), or less sharp (blunted)
E. Level of diaphragms; notes the rib level to determine if the film is of good or poor inspiratory quality
F. Stomach air bubble
G. Breast shadows
H. Traces the outline of each rib noting the angle and any fractures or other abnormalities
I. Tracheal position
J. Identifies the carina and the mainstem bronchi
K. Examines hila for size and position
L. Presence or absence of lung markings
M. Aortic knob and the heart shadow
N. Examines for silhouette sign
O. Measures and estimates the cardiothoracic ratio
P. Notes the presence and position of any artificial airways or catheters
7. States an overall impression of the film
8. Correlates the film with the clinical findings and interprets results
FOLLOW-UP
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PERFORMANCE RATING:

COGNITIVE DOMAIN
to modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch29_467-490.indd 490 08/02/13 4:52 PM

CHAPTER Pulmonary
Function
Testing
INTRODUCTION Many lung diseases develop insidiously over time. The pulmonary system has a
significant amount of functional reserve so that a large degree of dysfunction can occur
through illness or injury1 before outward signs and symptoms are noted. Detection of
lung dysfunction is important for the diagnosis, prevention, treatment, and rehabilitation
of patients with lung disease.
Pulmonary function testing (PFT) is a series of diagnostic tests devised to evaluate all
aspects of respiratory system function, including,1 but not limited to, the following:
1. Ventilatory volumes and capacities

2. Airway integrity through measurement of flows and resistance
3. Respiratory muscle strength
4. Mechanical properties of lungs and thoracic cage
5. Efficiency of gas exchange and function of alveolar-capillary membrane
6. Exercise response
7. Response to irritants and bronchoactive drugs
The goals of pulmonary function testing include the following1:
1. Determine the absence or presence of pulmonary disease abnormalities.

2. Allow for earlier detection and intervention.
3. Measure the severity of the disorder (degree of impairment and extent of disability—
how it affects daily activities).
4. Characterize the type of pathophysiology.
5. Follow the course of the disease and progression.
6. Measure the response to therapy regimens and rehabilitation efforts.
7. Perform preoperative evaluation that determines surgical risk for postoperative
pulmonary complications.
Pulmonary function testing has some limitations. One cannot identify specific diseases
entirely without other correlating information, such as the patient’s history and physical
examination and other diagnostic tests. The variable sensitivity of pulmonary function
tests and the large variability of what is considered normal make early detection difficult.
Four factors that play an important role in determining the validity and reliability of
pulmonary function testing are equipment use, technician competence, level of patient
cooperation and effort, and reproducibility of the results. Standards for equipment and
test performance help minimize variability and improve the reliability and validity of the
test results.
The respiratory care practitioner (RCP) will perform many different testing protocols for
various indications, including bedside assessment, screening, complete testing, and
specialized testing. This chapter focuses on simple spirometry, screening, protocols,
flow-volume loops, and postbronchodilator studies.
491
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OBJECTIVES 1. Practice communication skills needed for the active forceful coaching instruction of subjects
Upon completion of this performing a forced vital capacity (FVC) maneuver.
chapter, you will be able to: 2. Practice medical charting for maintaining legal records of pulmonary function results.
4. Calibrate and maintain volume displacement and flow-sensing spirometry equipment.
5. Perform valid and reliable pulmonary function testing of a slow vital capacity (SVC) and FVC
maneuver, postbronchodilator study, and maximum voluntary ventilation (MVV) according to
American Thoracic Society and European Respiratory Society (ATS/ERS) guidelines for
spirometry.
6. Interpret graphic representations of volume-time and flow-volume tracings of FVC maneuvers.
7. Manually calculate the FVC, FEV1, FEF25%–75%, predicted values, and percent predicted values
for a valid spirogram.
8. Interpret pulmonary function testing results.
9. Define the four lung volumes and four lung capacities and analyze their interrelationships.
KEY TERMS
calibration kymograph precision reproducibility
displacement nomogram recoil specificity
extrapolation plateau regression equation validity
intersection pneumotachometer reliability variability
Exercises
F 3-liter calibration syringe and adaptors F Marking pens
F BTPS conversion charts F Medical waste receptacles
F Calculators F Metric rulers
F Calibrated graph paper F Pencils
F Centigrade thermometer F Predicted values tables or nomograms
F Chair F Small-volume nebulizer, connecting tubing,
F Disposable flow sensors or in-line filters and gas source
F Disposable mouthpieces F Stopwatch
F Disposable nose clips F Tissues
F Flow-sensing spirometers F Unit-dose bronchodilators
F Main large-bore tubing F Volume displacement spirometers
EXERCISE 30.1 EQUIPMENT IDENTIFICATION

EXERCISE 30.1.1 IDEN TIFIC ATION O F V O LU ME D I S P LA C E ME N T S P I R O ME T E R S
Identify the types of volume displacement spirometers shown in Figure 30.1 and record them on
Wedge bellows
Dry-rolling seal
Water seal
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C H A P T E R 30 | P U LM O N A RY FUNC TION TES TING • 493
A B
C
Figure 30.1. Types of volume displacement spirometers.
EXER C ISE 30 .1 .2 IDEN TIF I C AT I O N O F FLO W-S E N S I N G S P I R O ME T E R S

(PN EUM O TA C H O ME T E R S )
Identify the types of flow-sensing spirometers (pneumotachometers) shown in Figure 30.2 and
Fleisch pneumotach or strain gauge (disposable)
Ultrasonic vortex-sensing spirometer
Hot wire anemometer
A B
C
Figure 30.2. Types of flow-sensing spirometers.
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EXERCISE 30.2 CALIBRATION AND MAINTENANCE OF SPIROMETRIC EQUIPMENT
1. Identify the type of spirometer and brand you use and record it on your laboratory
report.
2. Check to make sure you have an adequate paper supply. Note the paper speed of the
machine used (calibration in mm/second), and record it on your laboratory report.
3. Check to make sure the recording pen (if applicable) is functional and that spares are
available.
4. Plug the unit in, if applicable. If a computerized device is used, follow the manufacturer’s
instructions to enter the date and time.
5. If a volume displacement spirometer is used, check the unit for leaks by occluding the main
inlet and attempting to move the piston/bell/bellows connection where the recording pen
attaches. No movement should be observed if no leaks are present.
6. Attach the main tubing and repeat step 5. If a leak is detected, check the tubing for holes or
tears and replace as necessary.
7. If possible, turn on the recording device and make sure the pen is recording on the
baseline.
8. Check the room temperature. Enter it into your computerized spirometer as applicable.
Record the temperature in both Fahrenheit and Celsius on your laboratory report.
9. Using a 3-liter calibration syringe, check the spirometer for accuracy.
A. Turn the machine on and enter the calibration mode, if applicable, on a computerized
machine.
B. Pull back the plunger to set the syringe to the 3-liter volume.
C. Attach the syringe (an adapter may be required) securely to the main tubing or flow
sensing device.
D. Start the recording device or activate the machine according to manufacturer’s
directions, and push the entire 3-liter volume into the device. The calibration tracing will
appear as shown in Figure 30.3.
E. Record the measured volume on your laboratory report. According to ATS/ERS
standards, the spirometer must be accurate to 3.5% of the calibrating volume.2
F. Calculate the percent accuracy of your measurement by the following formula, and
record it on your laboratory report:
Measured volume/3 L × 100 = Percent accuracy
G. Repeat the calibration while varying the speed at which the calibration volume is
injected. Record your observations of how fast or slow the volume is injected and the
effects on the calibration volume on your laboratory report.
H. For volume displacement spirometers using a kymograph recording device, verify the
time calibration by checking the paper speed using a stopwatch. Make a mark on your
recording paper. Simultaneously start the recording device and activate the stopwatch.
At exactly 10 seconds, simultaneously stop the recording and the stopwatch. Verify that
10 seconds of recording paper have been used.
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Figure 30.3. Calibration tracing.
2679_Ch30_491-528.indd 495 07/02/13 4:46 PM

EXERCISE 30.3 RESPIRATORY HISTORY
Using your lab partner as 1. Introduce yourself and your department to your subject.
the patient, obtain a baseline 2. Briefly explain the purpose of the test and confirm your subject’s understanding by having
spirometry screening test. the subject repeat the instructions back to you.
This involves obtaining 3. Have your “patient” record his or her information on his or her own laboratory report.
three valid, reproducible Record your information on your laboratory report. Although you will be performing the
FVC maneuvers that meet test on your laboratory partner, for purposes of student confidentiality, use only your own
all ATS/ERS standards for information and test results for your laboratory report.
spirometry. Do not perform A. Name and identification number
the screening on anyone B. Age on day of testing
with an acute illness. C. Height in stocking feet
D. Gender
E. Race (indicate white or nonwhite for purposes of race correction according to NIOSH
and OSHA regulations for spirometry)
4. Determine whether previous testing has ever been done and whether it was done sitting or
standing. Record the information on your laboratory report.
5. Elicit a respiratory history by asking your subject the following questions. Record the
information on your laboratory report.
A. Do you usually have a cough first thing in the morning? Do you cough up any
secretions? If so, how much and what color is it usually?
B. Do you cough for as much as 3 months a year?
C. Do you ever experience chest tightness, wheezing, shortness of breath on exertion or at
rest, or chest pain? Describe quality and location. Are you having any chest pain now?
D. Have you ever had or been told you have asthma, allergies, pneumonia, chronic
bronchitis, emphysema, or tuberculosis?
E. Do you have a heart condition for which you are under a doctor’s care?
F. Do you take or have you ever taken prescription medicine for a respiratory or cardiac
illness? If so, what medications?
G. Do you take nonprescription medicine for a respiratory illness?
H. Smoking history:
i. Have you ever smoked?
ii. Do you smoke now?
iii. How many packs of cigarettes do/did you smoke per day?
iv. How old were you when you started smoking?
v. How long ago did you quit smoking?
vi. How many years/months have you been smoking?
vii. Calculate the patient’s pack/year history: [(Age now – Age started smoking) – years
since stopped smoking] × packs per day = packs/years. Show your work and answer
I. Occupational history:
i. What type of work do you presently do?
ii. What other types of work have you done in the past?
iii. Have you ever worked in mining, construction, or with insulation? Have you ever
been exposed to dusts, fumes, or mists at work?
J. Family history: List ages, state of health, age at death, and cause of death for mother,
father, and siblings.
EXERCISE 30.4 SPIROMETRY SCREENING
NOTE: Perform the following exercises with a volume displacement spirometer if available so
that you can practice hand calculation of the results as part of the laboratory exercises. Repeat
the exercise with a flow-sensing spirometer as well so you gain experience with both types of
equipment. Also, you must practice being both tester and subject in order to have appropriate
data to complete the laboratory report.
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EXER C ISE 30 .4 .1 IDEN TIF I C AT I O N O F LU N G V O LU ME S A N D C A PA C I T I E S

Identify the lung volumes and capacities labeled in Figure 30.4. Record them on your laboratory
report.
Figure 30.4. Lung volumes and capacities.
EXER C ISE 30 .4 .2 MEASU R I N G S P I R O ME T R I C LU N G V O LU ME S A N D C A PA C I T I E S

procedures as applicable.
2. Aseptically take a clean disposable mouthpiece or flow-sensing device and attach it to the
main tubing. If disposable pneumotachometers are used, each one should be calibrated
before use in testing.
3. Instruct the subject in the performance of a simple spirogram. Instruct the subject, when
indicated, to place the mouthpiece tightly between the teeth with the lips sealed, without the
tongue blocking the opening and without biting down, and to relax and breathe normally
in and out for five or six breaths. Observe for consistency of tidal volume and breathing
pattern. Instruct the subject to take the deepest breath possible and then blow it out slowly
until you say to stop. Confirm your subject’s understanding by having the subject repeat the
instructions back to you.
4. Place the nose clips on the subject and verify that there are no leaks. If the subject refuses to
use the nose clips, have the subject hold his or her nose if possible.
5. Have the subject sit or stand straight, chin slightly elevated. If the subject is obese,
pregnant, or a child, the test should be performed standing. A chair without wheels should
be placed behind the subject under these circumstances for safety.
6. Have the subject begin tidal breathing until a relaxed pattern is noted, and then activate the
machine and the recording device. Reinforce instructions throughout the test. Record five or
six tidal breaths.
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7. Actively coach the subject throughout inspiration and expiration to perform the SVC
maneuver. At the end of a normal exhalation, instruct the subject to take a maximal
inspiration until the lungs are completely full and then exhale slowly until the lungs are
completely empty. Remind the subject to continue exhaling until instructed to stop.
8. Observe the subject for adequate effort and proper performance during the maneuver.
Reinstruct as necessary.
9. Remove the nose clips and allow the subject to be seated if needed between tests.
10. Have the subject sign and date the tracing. Record the room temperature on your laboratory
report. Attach the spirogram tracing to the subject’s laboratory report. From the spirogram,
calculate the values listed on the laboratory report.
EXERCISE 3 0 .4 .3 P ERF ORMAN CE OF S LO W V I TA L C A PA C I T Y A N D FO R C E D V I TA L C A PA C I T Y

MAN EUV ERS
1. Determine whether there are any contraindications to the performance of a baseline
spirometry screening at this time by asking the subject the following questions (the
following mnemonic “FRED’S SAFE” may help you remember them):
“F” Have you had upper respiratory tract illness, inFluenza, or bronchitis within the
last 3 weeks?
“R” Are you wearing any tight or Restrictive clothing that may interfere with the
performance of the test?
“E” Have you Eaten a heavy meal within the last 2 hours?
“D” Do you have any Dental appliances, loose teeth, caps, gum, or candy in your
mouth? Note that dentures should usually be left in place to allow for an
adequate seal around the mouthpiece unless they are so loose that they may come
out during the test.
“S” Have you Smoked within the last hour?
“S” Have you had any recent Surgeries?
“A” Have you used an Aerosolized bronchodilator within the last 4 to 6 hours?
“F” How are you Feeling today? Do you have any acute illness at the present time?
“E” Have you had any Ear infections in the last 3 weeks?
2. If a positive response is obtained to any of the preceding questions, the problem should be
corrected or screening spirometry should be postponed for the appropriate length of time.
The subject must be free from any acute illness for at least 3 weeks before screening.3
5. Instruct the subject in the performance of the SVC maneuver. Explain (and demonstrate, if
necessary) the following:
A. When you indicate, the subject should take as deep a breath as possible, completely
filling his or her lungs.
B. The subject should place the mouthpiece tightly between the teeth with the lips sealed,
without the tongue blocking the opening and without biting down.
C. Without hesitation, the subject should then slowly blow the air out until the lungs are
as completely empty as possible, until you say to stop.
6. Confirm your subject’s understanding by having the subject repeat the instructions back
to you.
7. Place the nose clips on the subject and verify that there are no leaks. If the subject refuses
to use the nose clips, have the subject hold his or her nose if possible.
8. Have the subject sit or stand straight, chin slightly elevated. If the subject is obese, pregnant,
or a child, the test should be performed standing. A chair without wheels should be placed
behind the subject under these circumstances for safety.
9. Activate the machine and the recording device. Actively coach the subject throughout
inspiration and expiration, and perform the SVC.
11. Note the volume obtained and record it on your laboratory report.
12. Allow the subject time for adequate recovery. Remove the nose clips and allow the subject
to be seated if needed between tests.
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13. Replace the nose clips, reinstruct the subject, and repeat the SVC maneuver with active,
forceful coaching until three tracings of consistent volume are observed. The two best
volumes should be within 150 mL of each other.
14. Instruct the subject in the performance of the FVC maneuver. Explain (and demonstrate, if
necessary) the following:
A. When you indicate, the subject should take as deep a breath as possible, completely
filling his or her lungs.
B. The subject should place the mouthpiece tightly between the teeth with the lips sealed,
C. Without hesitation, the subject should then blow the air out as hard, fast, and
completely as possible, until you say to stop.
to you.
17. Have the subject sit, chin slightly elevated. If the subject is obese, pregnant, or a child, the
test should be performed standing. A chair without wheels should be placed behind the
subject under these circumstances for safety.
inspiration and expiration, and perform the FVC.
20. Note the volume obtained, the shape, and the appearance of the graphic representation, if
available.
21. Allow for adequate recovery of the subject. Remove the nose clips and allow the subject to
be seated if needed between tests.
22. Verify that the results meet ATS/ERS standards for acceptability. The FVC tracings should
be free from the following3:
A. Cough or glottic closure (Fig. 30.5).
B. Variable effort (Fig. 30.6).
C. Early termination (Fig. 30.7). A plateau should be achieved and is defined as no
change in volume in the last 1 second of the tracing. The test should be at least
6 seconds in duration. In subjects with severe chronic obstructive lung disease, the
spirometer should be capable of recording for at least 15 seconds. Failure to plateau
is shown in Figure 30.8.
D. Hesitation at the start of the test (Fig. 30.9). Extrapolated volume must be less than
5% of the FVC if the FVC is >3.00 liters or 150 mL if the FVC is <3.00 liters.
E. Baseline error or leaks.
F. Excessive variability. There should be less than 150-mL difference between the two
best FVC and FEV1 results.3
23. It is advisable to have the subject sign and date the spirometric tracing, due to the often
litigious nature of pulmonary disability or workers’ compensation cases. Attach it to his or
her laboratory report.
24. Repeat spirometry with a flow-sensing computerized spirometer. Attach the subject’s results
to his or her laboratory report for comparison.
25. Discard any disposable nose clips, mouthpieces, or flow sensors in an infectious waste
container when testing is completed. Disinfect any nondisposable mouthpieces and tubings
when finished with the laboratory.
2679_Ch30_491-528.indd 499 07/02/13 4:46 PM

Figure 30.5. Cough or glottic closure on a volume-time tracing. Shown at reduced size.
Variable effort
Figure 30.6. Variable effort on a volume-time tracing.
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Figure 30.7. Early termination on a volume-time tracing. Shown at reduced size.
2679_Ch30_491-528.indd 501 07/02/13 4:46 PM

Figure 30.8. Failure to plateau on a volume-time tracing. Shown at reduced size.
Figure 30.9. Hesitation at the start of the test on a volume-time tracing. Shown at reduced size.
2679_Ch30_491-528.indd 502 07/02/13 4:46 PM

EXERCISE 30.5 CALCULATION OF SPIROMETRIC RESULTS
Using your own graph obtained from a volume displacement spirometer, calculate the following.
Show your work and record the results on your laboratory report.
1. Determine validity as indicated by three acceptable FVC tracings free from the following:
Cough or glottic closure
Early termination of expiration
Variable effort
Baseline error
Excessive hesitation at start of test
2. Measure the SVC at the highest point of the plateau.
3. Measure the FVC in each tracing at the highest point of the plateau.
A. If there is no excessive variability, select the two best curves within 150 mL of each
other.
B. Select the largest FVC.
4. Calculate the variability between the SVC and FVC:
SVC – FVC / SVC × 100 = Percent
5. Using a metric ruler placed on the volume-time tracing, draw back-extrapolation lines on
all FVC tracings on the steepest portion of the curve, as shown in Figure 31.10.
A. The tracing is valid if the extrapolation volume is less than 5% or 150 mL of the FVC
on that curve (volume inside triangle as shown in Fig. 30.11).
B. Use the point at which the back-extrapolation line intersects the baseline (x axis) as
the zero point determination.
6. Measure the FEV1 on all three tracings by measuring the 1-second distance from the zero
point determined in step 3 (Fig. 30.12). Choose the best FEV1 regardless of which curve it is
from, even if it is not the same curve as the best FVC.
7. Calculate the FEV1/FVC% ratio.
FEV1/FVC × 100 = FEV1/FVC% (FEV1%)
8. Determine the BTPS correction factor from Table 30.1 using ambient temperature. Correct
all volumes and flow rates to BTPS. Do not correct the FEV1/FVC% ratio.
SVC × BTPS correction factor = SVC actual BTPS corrected
FVC × BTPS correction factor = FVC actual BTPS corrected
FEV1 × BTPS correction factor = FEV1 actual BTPS corrected
FEF25%–75% × BTPS correction factor = FEF25%–75% actual BTPS corrected
9. Determine predicted values from tables or nomograms. Correct for race if necessary.
(NOTE: If NHANES III predicted tables are used, then use the appropriate table for race
and do not correct for race.)
Predicted value × 0.85 = Race-corrected value
10. Calculate the percent predicted.
Actual (BTPS)/Predicted (race corrected if necessary) × 100 = Percent predicted
Figure 30.10. Measuring the extrapolation volumes under the curve. Shown at reduced size.
2679_Ch30_491-528.indd 503 07/02/13 4:46 PM

Figure 30.11. Measuring the FEV1 by measuring the 1-second distance from the zero point. Shown at reduced size.
Figure 30.12. Drawing the back extrapolation lines on all FVC tracings along the steepest portion of the curve. Shown at reduced size.
2679_Ch30_491-528.indd 504 07/02/13 4:46 PM

Table 30.1 BTPS Conversion Factors
Gas Temperature °C (ATPS) Conversion Factor
18 1.114
19 1.111
20 1.102
21 1.096
22 1.091
23 1.085
24 1.080
25 1.075
26 1.068
27 1.063
28 1.057
29 1.051
30 1.045
31 1.039
32 1.032
33 1.026
34 1.020
35 1.014
36 1.007
37 1.000
°C = 5 (°F – 32)/9
NOTE: Round all volumes to two decimal places and all percentages to one decimal place. Label
all results correctly.
11. FEF25%–75% (Fig. 30.13):
A. Choose the “best” curve (i.e., the one with best sum of FEV1 and FVC).
B. Calculate 25% of FVC. Calculate 75% of FVC. Mark 25% and 75% points on the
curve.
C. Draw a line connecting the 25% and 75% points.
D. Find any two points A and B that are 1 second apart on the FEF line.
E. Measure the volumes at points A and B (note that these are not the 25% and
75% points).
F. Subtract the difference in volume (point B – A).
G. Correct for BTPS. Answer in liters per second.
H. Obtain a predicted value for the FEF25%–75%.
2679_Ch30_491-528.indd 505 07/02/13 4:46 PM

Figure 30.13. FEF25%–75% calculation. Shown at reduced size.
EXERCISE 30.6 POSTBRONCHODILATOR STUDY
If any students presently 1. Have the subject administer the bronchodilator via MDI or SVN as previously instructed
have a prescription for (Chapter 15).
bronchodilators, a 2. Repeat Exercise 30.4.3.
prebronchodilator– 3. Calculate the percent change in FEV1 as follows, and record on your laboratory report:
postbronchodilator FEV1 postbronchodilator – FEV1 prebronchodilator/FEV1 prebronchodilator × 100
comparison may be done 4. Calculate the percent change in FEV1/FVC ratio (FEV1%) as follows, and record on your
with the student’s consent. laboratory report:
FEV1% pre – FEV1% post = Percent change
EXERCISE 30.7 MAXIMUM VOLUNTARY VENTILATION
1. Introduce yourself and your department to your subject.

2. Briefly explain the purpose of the test. Confirm your subject’s understanding by having the
subject repeat the instructions back to you.
4. Aseptically attach the mouthpiece to the main tubing.
2679_Ch30_491-528.indd 506 07/02/13 4:46 PM

Best maximum voluntary ventilation
Figure 30.14. MVV tracing.
5. Instruct the subject in the performance of the test. Explain that he or she will be breathing as
rapidly and deeply as possible for 12 to 15 seconds (depending on the device used).
6. With the subject seated, actively coach him or her to begin breathing as rapidly and deeply as
possible. Activate the machine and obtain a tracing (Fig. 30.14). Record the result on your
laboratory report and attach the tracing.
7. Multiply the volume achieved by 5 (for a 12-second observation) or 4 (for a 15-second
observation) to obtain the volume per minute. Record the duration of the test on your
laboratory report. Record the result on your laboratory report.
EXERCISE 30.8 FLOW-VOLUME LOOPS
If the spirometer you are using is capable of performing a flow-volume loop, follow the manufac-
turer’s directions and complete the following:
1. Introduce yourself and your department to the subject.
2. Explain the purpose of the test. Confirm understanding by having the subject repeat the
instructions back to you.
3. Obtain subject information (age, gender, height, weight, and race) and enter the data into
the spirometer.
6. Instruct the subject in the performance of the flow-volume loop maneuver. Explain (and
demonstrate, if necessary) the following:
A. The subject should place the mouthpiece tightly between the teeth with the lips sealed,
B. When you indicate, the subject should take as deep a breath as possible, completely
filling the lungs.
C. Without hesitation, the subject should then blow the air out as hard, fast, and
completely as possible, until you say to stop. As soon as the subject’s lungs are empty,
the subject should take a maximum deep breath without removing the mouthpiece.
to you.
9. Have the subject sit or stand straight, chin slightly elevated. If the subject is obese,
pregnant, or a child, the test should be performed standing. A chair without wheels should
be placed behind the subject under these circumstances for safety.
inspiration and expiration, and perform the flow-volume loop.
12. Note the volume obtained on the first effort and the shape and appearance of the graphic
representation if available.
13. Allow for adequate recovery of the subject. Remove the nose clips and allow the subject to
be seated if needed between tests.
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14. Replace the nose clips, reinstruct the subject, and repeat the maneuver with active, forceful
coaching until three acceptable tracings are obtained according to ATS/ERS standards. The
three tracings should be free from the following:
Cough or glottic closure (Fig. 30.15)
Variable effort (Fig. 30.16)
Early termination (Fig. 30.17)
Hesitation at the start of the test (Fig. 30.18). The extrapolated volume must be less
than 5% of the FVC or 150 mL, whichever is greater.
Baseline error
Excessive variability. There should be no more than a 150-mL difference between the
two best FVC and FEV1 results.
15. Have the subject sign and date the spirometric tracing. Attach it to his or her laboratory
report.
Figure 30.15. Flow-volume loop with cough or glottic closure. Figure 30.16. Flow-volume loop with variable effort.
Figure 30.17. Flow-volume loop with early termination. Figure 30.18. Flow-volume loop with hesitation at the start of the test.
2679_Ch30_491-528.indd 508 07/02/13 4:46 PM

R E FE R E N C E S
1. American Association for Respiratory Care: AARC clinical practice guideline: Spirometry, 1996 Update. Respir Care 41(7):629–636, 1996.
2. Miller, MR, et al: ATS/ERS Task Force: Standardisation of lung function testing. Standardisation of spirometry. Eur Respir J 26:319–338,
2005, p. 322.
3. Miller, MR, et al: ATS/ERS Task Force: Standardisation of lung function testing. Standardisation of spirometry. Eur Respir J 26:319–338,
2005, p. 325.
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2679_Ch30_491-528.indd 510 07/02/13 4:46 PM
Laboratory Report
CHAPTER 30: PULMONARY FUNCTION TESTING
Name: Date:
Data Collection
EXERCISE 30.1 Equipment Identification
E X E R C IS E 30 . 1. 1 ID E NT IFIC ATION OF VOL UME DISPL ACEMEN T SPIROMETERS
A. _____________________________________________________
B. _____________________________________________________
C. _____________________________________________________
E X E R C IS E 30 . 1. 2 ID E NT IFIC ATION OF F L OW-SEN SIN G SPIROMETERS (PN EUMOTACHOM ETERS)
A. _____________________________________________________
B. _____________________________________________________
C. _____________________________________________________
EXERCISE 30.2 Calibration and Maintenance of Spirometric Equipment
Type: _____________________________________________________
Brand: ____________________________________________________
Paper speed (calibration mm/sec): ______________________________
Room temperature: ___________________ °F ( _________________ °C)
Calibration volume: __________________________________________
Percent accuracy (Show your work): ____________________________
Calibration injection speed observations: ____________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
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EXERCISE 30.3 Respiratory History
Name and identification number: _______________________________
Age on day of testing: ________________________________________
Height in stocking feet: _______________________________________
Gender: ___________________________________________________
Race: _____________________________________________________
Previous testing: ____________________________________________
Sitting or standing: __________________________________________
Respiratory history:
Do you usually have a cough first thing in the morning? _________________________________________________________________
Do you cough up any secretions? ________ If so, how much and what color is it usually? _____________________________________
Do you cough for as much as 3 months a year? _______________________________________________________________________
Do you ever experience chest tightness, wheezing, shortness of breath (on exertion or at rest), or chest pain (quality and duration)?
_____________________________________________________________________________________________________________
Have you ever had or been told you have asthma, allergies, pneumonia, chronic bronchitis, emphysema, or tuberculosis?
_____________________________________________________________________________________________________________
Do you have a heart condition for which you are under a doctor’s care? Do you have any chest pain now?
_____________________________________________________________________________________________________________
Do you take or have you ever taken prescription medicine for a respiratory or cardiac illness? If so, what medications?
_____________________________________________________________________________________________________________
Do you take nonprescription medicine for a respiratory illness? __________________________________________________________
Smoking history:
Have you ever smoked?__________________________________________________________________________________________
Do you smoke now?_____________________________________________________________________________________________
How many packs of cigarettes do/did you smoke per day?_______________________________________________________________
At what age did you start smoking?_________________________________________________________________________________
How long ago did you quit smoking? ________________________________________________________________________________
How many years/months have you been smoking? _____________________________________________________________________
Calculate the subject’s pack/year history (Show your work): _____________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
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Occupational history:
What type of work do you presently do? _____________________________________________________________________________
What other types of work have you done in the past?___________________________________________________________________
Have you ever worked in mining, in construction, or with insulation? ______________________________________________________
Have you ever been exposed to dusts, fumes, or mists at work? __________________________________________________________
Family history:
Mother: ______________________________________________________________________________________________________
Father: _______________________________________________________________________________________________________
Siblings: ______________________________________________________________________________________________________
EXERCISE 30.4 Spirometry Screening
E X E R C IS E 30 . 4. 1 ID E NT IFIC ATION OF L UN G VOL UMES AN D CAPACITIES
A. _____________________________________________________
B. _____________________________________________________
C. _____________________________________________________
D. _____________________________________________________
E. _____________________________________________________
F. _____________________________________________________
G. _____________________________________________________
H. _____________________________________________________
E X E R C IS E 30 . 4. 2 ME A S U R ING SPIROMETRIC L UN G VOL UMES AN D CAPACITIES
Room temperature: ________________ From the attached spirogram, measure all tidal breaths recorded: _______________________
Average the VT (Show your work): ____________________________
________________________________________________________
Correct for BTPS: VT × BTPS correction factor: __________________
Calculate the following from the spirometric tracing:
IC (BTPS) = ______________________________________________
IRV (BTPS) = _____________________________________________
VC (BTPS) = ______________________________________________
ERV (BTPS) = _____________________________________________
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E XE RCI SE 3 0 .4 . 3 P E R FO R MA N C E O F S L O W VITAL CAPACITY AN D F ORCED VITAL CAPACITY MAN EUVERS
Recorded SVC:____________________________________________
Attach results from volume displacement and flow-sensing spirometer.
EXERCISE 30.5 Calculation of Spirometric Results
Attach the spirometric volume-time tracing obtained with your measurements and calculate the following (Show your work):
Date: ___________________________________________________
Time: ___________________________________________________
Temperature: _____________________________________________
FVC results:
1. _____________________________________________________
2. _____________________________________________________
3. _____________________________________________________
SVC results: ______________________________________________
Variability for FVC: ________________________________________
Percent variability between SVC and FVC: ______________________
FEV1 results:
1. _____________________________________________________
2. _____________________________________________________
3. _____________________________________________________
Whose predicted values used: _______________________________
Best FEV1 (BTPS): _________________________________________
FEV1 predicted: ___________________________________________
FEV1 percent predicted: _____________________________________
Best FVC (BTPS): __________________________________________
FVC predicted: ____________________________________________
FVC percent predicted: _____________________________________
FEV1/FVC%: ______________________________________________
FEF25%–75%: _______________________________________________
Compare your hand-calculated results with the computerized spirometric results: ____________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
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EXERCISE 30.6 Postbronchodilator Study
Attach results of postbronchodilator study, if applicable. Compare prebronchodilator and postbronchodilator results:
Percent change FEV1: ______________________________________
Percent change FEV1/FVC%: _________________________________
EXERCISE 30.7 Maximum Voluntary Ventilation
Duration (seconds) of test: __________________________________
MVV: ______________________________________________ L/min
EXERCISE 30.8 Flow-Volume Loops
Attach the results of the flow-volume loop, if available.

1. What lung volumes and capacities cannot be measured directly by spirometry?
2. Identify three methods to measure the volumes and capacities listed in Critical Thinking Question 1.
3. What is considered a significant change in preshift to postshift, or prebronchodilator to postbronchodilator, spirometric

results? What factors might account for a change in spirometric values from preshift to postshift workers?
4. What is considered a significant change in annual spirometric results? What factors might account for changes in
annual spirometry?
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5. Calculate the following (Show your work):
VT = 500 mL
IRV = 3,000 mL
ERV = 1,000 mL
RV = 1,500 mL
A. TLC = ____________________
B. VC = _____________________
C. IC = _____________________
D. FRC = ____________________
6. Calculate the following (Show all work):
VT = 400 mL
IC = 1,000 mL
FRC = 3,000 mL
ERV = 600 mL
A. VC = _____________________
B. TLC = ____________________
C. RV = _____________________
D. IRV: _____________________
7. Calculate the following (Show all work):
TLC = 6,000 mL
FRC = 3,500 mL
ERV = 1,500 mL
VT = 500 mL
A. VC = _____________________
B. IC = _____________________
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8. For the flow-volume loop shown in Figure 30.19, calculate the FVC, FIVC, PEFmax (peak expiratory flow), PIFmax (peak
inspiratory flow), and ratio of PEF50%/PIF50%.
Figure 30.19. Flow-volume loop for calculation.
9. What would sawtoothing on the inspiratory loop of a flow-volume tracing most likely represent?
10. Interpret the following pulmonary function tests:
A. A 39-year-old man has a chief complaint of shortness of breath on exertion. Results of the spirometry screening
are as follows:
Prebronchodilator Predicted % Predicted Postbronchodilator % Predicted

FVC 4.09 L 4.64 L 88.1% 4.00 L 86.2%
FEV1 1.94 L 3.73 L 52.0% 1.98 L 53.1%
FEV1/FVC% 47.4% 80.4% — 49.5% —
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B. A slightly dyspneic coal miner who is a heavy smoker has a respiratory rate of 25/minute with the following
ABG and PFT results:
pH = 7.43
Paco2 = 50 mm Hg
Hco3– = 32 mm Hg
Pao2 = 55 mm Hg (drawn breathing room air)
Predicted Actual
VC 4.4 L 3.0 L
FEV1 3.4 1.8 L
FEF25%–75% 3.8 L/sec 2.0 L/sec
DLCO 26 24
MVV 150 Lpm 85 Lpm
FRC 6.0 L 4.0 L
C. John Bart, 40 years of age, 72 inches tall, and 165 pounds, had been working in the steel mill since he was
17 years old. During the past 6 months he has been experiencing worsening of his shortness of breath. He is
now not able to work. He quit smoking 1 week ago. He had been smoking one pack a day since he was 16.
Results are as follows:
Spirometry Prebronchodilator Predicted % Predicted Postbronchodilator % Predicted

FVC 3.25 L 5.42 60.0% 3.22 L 59.4%
FEV1 2.30 L 4.08 L 56.4% 2.35 L 57.6%
FEV1/FVC % 70.8 75.3 — 73.0 —
FEF25%–75% 1.59 L/sec 4.55 L/sec 35.0% 1.77 L/sec 38.9%
MVV 88 Lpm 147 Lpm 60.0% 95 Lpm 64.6%
FRC 2.98 L 4.20 L 71.0%
RV 1.52 L 2.20 L 69.0%
TLC 4.77 L 7.62 L 63.0%
RV/TLC% 31.9% 28.9%
DLco 8.4 30.9 27.2%
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STUDENT: DATE:
SCREENING SPIROMETRY
PERFORMANCE LEVEL
PERFORMANCE RATING
Performance Level:
NA = Not applicable
Performance Rating:

2. Plugs the unit in if applicable; enters the date and time and patient information; confirms that correct normal values are being utilized
3. If a volume displacement spirometer is used, checks the unit for leaks
4. Turns on the recording device and makes sure the pen is recording on the baseline, if applicable
5. Checks and enters the room temperature
6. Using a 3-liter calibration syringe, checks the spirometer for accuracy; calculates and records the percent accuracy
A. Repeats the calibration while varying the speed of volume injection; ensures it is within 3.5%

8. Assesses subject by obtaining the following information:
A. Name and identification number
B. Age on day of testing
C. Height in stocking feet (or arm span, if subject unable to stand)
D. Gender
E. Race; indicate as white or nonwhite for purposes of race correction according to NIOSH and OSHA regulations for spirometry
9. Determines if previous testing has ever been done and whether it was done sitting or standing
10. Elicits a respiratory history including cough/sputum production, smoking history, dyspnea at rest and on exertion, medications,
employment history, and previous illnesses
11. Determines if there are any contraindications to the performance of a baseline spirometry screening at this time by asking the subject
the following questions: (acronym FREDS SAFE)
A. (F) Upper respiratory tract illness, influenza, or bronchitis within the last 3 weeks?
B. (R) Wearing any tight or restrictive clothing that may interfere with the performance of the test?
C. (E) Eaten a heavy meal within the last 2 hours?
D. (D) Any dental appliances, loose teeth, caps, gum or candy in your mouth? Remove as appropriate.
E. (S) Have you smoked within the last hour?
F. (S) Recent surgeries?
G. (A) Used an aerosolized bronchodilator within the last 4 to 6 hours?
H. (F) How are you feeling today? Do you have any acute illness at the present time?
I. (E) Ear infections in the last 3 weeks?
J. If a positive response is obtained to any of the above questions, corrects problems or postpones test for the appropriate time period.
12. Aseptically attaches clean disposable mouthpiece or flow-sensing device to the main tubing; calibrates as needed
13. Instructs the subject in the performance of the SVC maneuver and confirms the subject’s understanding
Continued
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STUDENT: DATE:
SCREENING SPIROMETRY (continued)
PERFORMANCE LEVEL
PERFORMANCE RATING
14. Places the nose clips on the subject and verifies that there are no leaks
15. Positions the subject by instructing him or her to sit or stand straight as appropriate, with chin slightly elevated; places a chair without
wheels behind the subject if standing
16. Activates the machine and recording device; actively coaches the subject throughout inspiration and expiration and performs the SVC
17. Observes the subject for adequate effort and proper performance during the maneuver; reinstructs as necessary
18. Notes the volume obtained
19. Allows for adequate time for subject recovery
20. Repeats the SVC maneuver with active, forceful coaching until three tracings within 150 mL of each other are obtained
21. Instructs the subject in the performance of the FVC maneuver and confirms the subject’s understanding
22. Places the nose clips on the subject and verifies that there are no leaks; repositions the subject
23. Activates the machine and performs FVC with active, forceful coaching throughout
24. Observes the subject for adequate effort and proper performance during the maneuver; reinstructs as necessary
25. Notes the volume obtained and the shape and the appearance of the graphic representation if available
26. Allows for adequate time for subject recovery
27. Determines the validity of the test:
A. Three acceptable tracings free from:
1) Cough or glottic closure
2) Early termination of expiration
3) Variable effort
4) Baseline error
5) Excessive hesitation at start of test
B. Extrapolated volume must be less than 5% of the FVC or 150 mL, whichever is greater
C. Plateau is defined as no change in volume in the last 1 second of the tracing
D. The test should be at least 6 seconds in duration
E. Excessive variability: there should be less than 150 mL difference between the two best FVC and FEV1 results
28. Compares the SVC and FVC volumes and explains any discrepancies
29. If a postbronchodilator test is ordered, administers the medication, waits an appropriate length of time, and repeats the FVC
A. Calculates the percent change in FEV1
B. Calculates the percent change in FEV1/FVC ratio (FEV1%)
30. Instructs the subject in the MVV maneuver, if appropriate, and confirms understanding
A. With the subject seated, has the subject begin breathing as rapidly and deeply as possible
B. Activates the machine and actively coaches the test performance for 12–15 seconds
C. Allows for adequate time for subject recovery
D. Multiplies the volume achieved by 6 or 4 to obtain the volume/minute; records the results
E. Repeats the test; assures variability no greater than 10%
FOLLOW-UP
32. Has the subject sign and date the spirometric tracing
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PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
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STUDENT: DATE:
FLOW-VOLUME LOOP (FVL)
PERFORMANCE LEVEL
PERFORMANCE RATING
Performance Level:
NA = Not applicable
Performance Rating:


3. Properly calibrates equipment with a 3-L calibration syringe
4. Properly sets up equipment for the FVL maneuver
5. Gathers the necessary patient demographic information
6. Instructs the patient in the proper performance of the maneuver
7. Demonstrates the performance of the FVL maneuver correctly
8. Uses nose clips according to facility policy
9. Instructs the patient in the proper placement of the mouthpiece
10. Forcefully coaches the patient in the expiratory maneuver
11. Forcefully coaches the patient in the inspiratory maneuver
12. Determines validity according to ATS/ERS guidelines
13. Repeats the maneuver as necessary
14. Allows the patient to rest sufficiently in between tests
15. Performs a postbronchodilator FVL if ordered
16. Analyzes the results for accuracy
FOLLOW-UP
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PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
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STUDENT: DATE:
MAXIMUM VOLUNTARY VENTILATION (MVV)
PERFORMANCE LEVEL
PERFORMANCE RATING
Performance Level:
NA = Not applicable
Performance Rating:


3. Properly calibrates equipment with a 3-L calibration syringe
4. Properly sets up equipment for the MVV maneuver
5. Gathers the necessary patient demographic information
6. Instructs the patient in the proper performance of the maneuver
7. Demonstrates the performance of the MVV maneuver correctly
8. Uses nose clips according to facility policy
9. Instructs patient in proper placement of the mouthpiece
10. Forcefully coaches the patient to breath as rapidly and as deeply as possible for 10–12 seconds
11. Forcefully coaches the patient during the entire maneuver
12. Allows the patient to rest sufficiently
13. Analyzes the results for accuracy
FOLLOW-UP
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PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
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STUDENT: DATE:
SPIROMETRY SCREENING INTERPRETATION
PERFORMANCE LEVEL
PERFORMANCE RATING
Performance Level:
NA = Not applicable
Performance Rating:


3. Performs spirometry as ordered by the physician
4. Interprets the following values by comparing actual values to predicted values:
FVC
FEV1
FEV1/FVC%
5. Analyzes the shape of the volume-time tracing and flow-volume loop
6. Determines if the results are within normal limits or abnormal
7. Accurately determines if the results are obstructive, restrictive, or a mixed pattern of disease
8. Accurately determines if results are mild, moderate, or severe
9. Determines the degree of effectiveness of bronchodilator administration
FOLLOW-UP
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PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
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CHAPTER Electrocardiography
INTRODUCTION Electrocardiography (ECG) is performed to assess the electrical activity of the heart. It
can be used for both diagnostic and monitoring purposes and is an integral part of
the assessment for any patient with chest pain or symptoms that suggest myocardial
infarction or cardiac dysfunction.1 Respiratory care practitioners (RCPs) perform many
procedures that can also affect cardiac function and electrical conduction. For this reason,
the RCP must be able to monitor changes in heart rate and rhythm during therapeutic
procedures and transport, as well as perform the ECG when necessary.2 The RCP
also plays an important role on rapid response teams; your monitoring provides vital
information that allows the team to recognize early signs of cardiac dysfunction and
accurately manage various cardiac arrhythmias during emergency procedures.3,4
OBJECTIVES 1. Identify normal anatomy of the heart and electrical conduction system.
Upon completion of this 2. Perform a 12-lead ECG recording.
3. Identify and correct common causes of artifacts that may interfere with the ECG.
4. Analyze and interpret ECG tracings for rate and rhythm, including normal sinus rhythm and
common dysrhythmias.
5. Relate the pharmacological treatments of choice according to American Heart Association
(AHA) advanced cardiac life support (ACLS) standards for common life-threatening
dysrhythmias.
KEY TERMS
artifact defibrillation infiltrate myocardial infarction
atrium depolarization infiltration (infiltrates) repolarization
cardiomegaly fibrillation isoelectric unifocal
cardioversion infarction multifocal ventricle
529
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Exercises
F 4×4 nonsterile gauze F ECG recording paper
F Anatomical heart model F Electrical outlets
F Alcohol prep pads F Electrocardiograph (ECG) machine
F Bed linens F Electrode gel
F Bed or table F Infectious waste container
F Clean towels or washcloths F Limb and chest leads
F Disposable ECG electrode pads F Privacy screen
F ECG calipers F Ventilator, compressor, or any other large
F ECG monitor or Holter monitoring system, if piece of electrical equipment
available
EXERCISE 31.1 CARDIAC ANATOMY
Obtain an anatomical model Using the model and the following word bank, label Figure 31.1, anatomy of the heart, and
of the heart. Figure 31.2, cardiac conduction system, and record on your laboratory report.
Pulmonic (semilunar) valve
Chordae tendinae
Papillary muscles
Aortic (semilunar) valve
Brachiocephalic artery
Superior vena cava
Left ventricle
Mitral valve
Left pulmonary veins
Left atrium
Left pulmonary artery
Right atrium
Tricuspid valve
Inferior vena cava
Aortic arch
Left subclavian artery
Left common carotid artery
Left bundle branch
Right ventricle
Sinoatrial (SA) node V U
A
Left atrium
T
Purkinje fibers S
Atrioventricular (AV) node B
R
Left ventricle
Right bundle branch Q
C
Right atrium P
Bundle of His (AV bundle)
Right pulmonary artery D O
Right pulmonary veins
Right ventricle N
Apex E M
Interventricular septum
F
Figure 31.1. Label the anatomy of the heart: vessels, valves,

and chambers. (From Scanlon, VC, and Sanders, T: Essentials H
L
of Anatomy and Physiology, ed. 2. FA Davis, Philadelphia,
1991, p. 266, with permission.) I J K
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C H A P T E R 31 | E LEC TR OC AR DIOGR AP HY • 531
B
F
C
D
H
I
Figure 31.2. Cardiac conduction system. (From
Scanlon, VC, and Sanders, T: Essentials of
Anatomy and Physiology, ed. 2. FA Davis,
Philadelphia, 1991, p. 271, with permission.) J
EXERCISE 31.2 IDENTIFICATION OF ELECTROCARDIOGRAPH MACHINE CONTROLS
Depending on laboratory Identify the following controls on the ECG machine provided:
resources, your instructor On/off switch
will provide you with either Stylus position
a single-channel or a Lead marker
multichannel ECG machine. Calibration standard
In either case, certain Lead selector
features are common to Sensitivity
all ECG machines. Paper speed
Identify the type of machine used and the specific controls found on this machine. Record on
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EXERCISE 31.3 PREPARATION AND ATTACHMENT OF LIMB LEADS
You will perform the 1. Gather the necessary equipment:

following exercise on F ECG machine
your laboratory partner F Limb leads
or instructor. F Disposable electrodes or reusable electrodes and gel
F Alcohol prep pads
3. Introduce yourself to the subject, verify the subject’s identification, and explain the
procedure.
4. Have the subject remove all jewelry or metal.
5. Place the subject in a supine position on the bed or table.
6. Plug in the ECG machine. Ensure that there is an adequate paper supply.
7. Apply clean electrodes to the muscular areas of the arms and legs, as shown in
Figure 31.3. The placement should be in a similar location on both arms and legs.
Avoid placing the electrodes on any bony prominences.
NOTE: In the case of limb deformities or amputation, the electrode should be placed on the torso
as close to the point of limb attachment as possible.
It may be necessary to prepare the skin by rubbing it with an alcohol prep pad before electrode
application. Excess body hair may interfere with the contact of an individual electrode; conse-
quently, in a clinical situation, the area may need to be shaved before electrode application. For
the purposes of this lab, shaving will not be performed.
If disposable electrode pads are used, peel off the backing and stick the pads securely to the sub-
ject’s skin. If nondisposable electrodes are used, apply an alcohol prep pad or electrode gel to the
skin first.
NOTE: The limb leads may be color coded or alphabetically coded as follows:
Electrode Location Color

Right arm (RA) White
Right leg (RL) Green (ground electrode)
Left arm (LA) Black
Left leg (LL) Red
Chest Brown
8. Instruct the subject to attempt to relax completely.

9. If the machine is capable of recording single-channel leads, record the tracings for limb
leads I, II, III, AVR, AVL, and AVF at this time.
or
RA LA
RA LA
RL LL
RL LL
Figure 31.3. Limb leads. (From Jones, SA: ECG Success:
Exercises in ECG Interpretation. FA Davis, Philadelphia,
2008, Figure 2.2, p. 10, with permission.)
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10. Turn the machine on.
11. Turn to the record position. Check that the stylus is centered on the paper.
12. Make sure the paper speed is set at 25 mm/second.
13. Press the calibration standard mark at the beginning of each tracing (if it is not done
automatically). Adjust the sensitivity as necessary so that the size of the complex is not too
large or too small.
14. Run each lead for at least 6 seconds (approximately 6 inches). Use the lead marker to
identify each lead recorded (if it is not done automatically).
15. Document the subject’s name, date, and time of the recording on the ECG tracing when
finished.
Attach the ECG tracing to your laboratory report. If only one subject is used to demonstrate to
the class, have the instructor make copies of lead II for each student in the class and attach the
copy to your laboratory report. Alternatively, you may run a long strip so that a minimum of a
6-second strip is available for each student in the laboratory.
You may continue with your partner for Exercise 31.4. However, if you are not performing
Exercise 31.4 at this time, you should disconnect and remove the leads from your subject and
clean up now. See Exercise 31.6 for directions.
EXERCISE 31.4 PREPARATION AND ATTACHMENT OF PRECORDIAL (CHEST) LEADS

EXER C ISE 31 .4 .1 S TAN DA R D C H E S T LE A D S
Because the chest leads 1. Place a small amount of ECG electrode gel on the skin over the correct position before
must be attached to bare electrode placement.
skin, it is preferable that a 2. Place the chest electrodes in the following locations, as shown in Figure 31.4:
volunteer be used for this V1: Fourth intercostal space, right sternal margin
exercise. You should not V2: Fourth intercostal space, left sternal margin
perform a 12-lead ECG on V3: Midway between V2 and V4
a female student without V4: Fifth intercostal space, left midclavicular line (MCL)
the permission of the female V5: Fifth intercostal space, left anterior axillary line (AAL)
student and the instructor. V6: Sixth intercostal space, left midaxillary line (MAL)
Adequate privacy should 3. Record the ECG tracing for each precordial lead, making sure to mark the calibration
be ensured. The chest, or standard and lead marker for each lead.
precordial, leads are 4. If you are using a multichannel 12-lead ECG machine, record the entire 12-lead ECG at
recorded with either a this time.
single electrode or multiple 5. Document the subject’s name, the date, and the time of the recording on the ECG tracing.
electrodes. If you use a Attach the tracing to your laboratory report. If only one subject is used to demonstrate to
single chest electrode, the class, have the instructor make copies of V5 for each student, and attach the copy to
you must reposition it your laboratory report.
before recording each
precordial lead.
Figure 31.4. Precordial chest leads in relation to ribs.

(From Lipman, BC, and Cascio, T: ECG Assessment and
Interpretation. FA Davis, Philadelphia, 1994, p. 16, with
permission.)
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EXERCISE 3 1 .4 .2 MODIFIED C HES T L E A D S

The accompanying figures
show modified leads
used for continuous ECG
monitoring (Fig. 31.5) and
for ambulatory or Holter
monitoring (Fig. 31.6). If
an ECG monitor or Holter
monitor is available,
students should place
electrodes on the chest
as shown and run a strip.
Figure 31.5. Modified chest lead MCL1. (From Lipman, BC, and Cascio,
T: ECG Assessment and Interpretation. FA Davis, Philadelphia, 1994, p. 20,
with permission.) Lead MCL1
Figure 31.6. Ambulatory or Holter monitoring. (Adapted from

Lipman, BC, and Cascio, T: ECG Assessment and Interpretation.
EXERCISE 31.5 ELECTROCARDIOGRAPH ARTIFACT

EXERCISE 3 1.5.1 IDEN TIFIC ATION O F A R T I FA C T
Match the ECG rhythm strips in Figures 31.7 through 31.10 with the following artifacts and re-
cord them on your laboratory report:
Muscle tremor
Wandering baseline
Intermittent loss of signal
60-cycle interference
Figure 31.7. Tracing A. (From Frew, MA, Lane, K,

and Frew, DR: Comprehensive Medical Assisting,
permission.)
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Figure 31.8. Tracing B. (From Frew, MA, Lane,

K, and Frew, DR: Comprehensive Medical
Assisting, ed. 3. FA Davis, Philadelphia, 1995,
Figure 31.9. Tracing C. (From Brown, KR, and Jacobson, S: Mastering Dysrhythmia: A Problem-Solving Guide. FA Davis, Philadelphia, 1988, p. 164, with
permission.)
Figure 31.10. Tracing D. (From Brown, KR, and Jacobson, S: Mastering Dysrhythmia: A Problem-Solving Guide. FA Davis, Philadelphia, 1988, p. 173, with
permission.)
EXER C ISE 31 .5 .2 S IMUL AT I O N O F A R T I FA C T

1. Prepare your patient as instructed in Exercise 31.3.
2. For steps 3 through 7, record your observations on, or attach the ECG tracing to, your
laboratory report.
3. Set the ECG machine to record lead II. Have the subject perform the following maneuvers
to simulate ECG artifacts while recording the ECG tracing.
A. Have the subject take deep breaths for several seconds.
B. Have the subject tense his or her muscles for several seconds.
C. Have the subject move his or her limbs.
D. Have the subject touch the metal bed rails or ECG machine while recording.
Alternatively, you may plug in another electrical device into the same electrical
outlet while recording the ECG.
4. Loosen the right electrode lead.
5. Loosen the left electrode lead.
6. Reverse the right and left electrode leads.
7. If nondisposable electrodes are used, replace one without using electrode gel or alcohol
prep pad.
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EXERCISE 31.6 CLEANUP PROCEDURES
1. Remove the electrodes gently, especially if disposable electrodes are being used over body
hair.
2. Clean off the skin using a washcloth or towel.
3. Discard the disposable electrodes in an infectious waste container.
4. Thoroughly clean and disinfect nondisposable electrodes before storage. Follow
manufacturer’s recommendations.
5. Neatly store limb leads and other supplies.
EXERCISE 31.7 RATE AND RHYTHM INTERPRETATION
1. To calculate the heart rate, you may use one of three methods:
A. Estimate by counting the number of QRS complexes on a 6-second strip and multiplying
by 10 (Fig. 31.11).
B. Use the RR method by first finding a QRS complex in which the peak of the R wave
falls on a heavy, dark line. Then find the next QRS complex. For each dark line between
the R waves, count backward (300, 150, 100, and so on) until you reach the second
QRS, as shown in Figure 31.12.
C. Use the calipers to count the number of small boxes between two R waves, and divide
that number into 1,500 (Fig. 31.13). This is the most accurate method.
2. Each small box is equal to 0.04 second. Each large box contains five small boxes across for
duration of 0.20 second. Examine the PR intervals and the QRS widths on the rhythm strips
obtained from previous exercises. Measure duration of each in seconds, and record the
Figure 31.11. A 6-second strip. (From Lipman, BC and Cascio, T: ECG Assessment and Interpretation. FA Davis, Philadelphia, 1994, p. 67, with permission.)
300 150 100 75 60 50
Figure 31.12. RR method of calculating rate

on an ECG. (From Jones, SA: ECG Success:
Exercises in ECG Interpretation. FA Davis,
Philadelphia, 2008, Figure 2.14, p. 15, with
permission.)
2679_Ch31_529-552.indd 536 07/02/13 4:47 PM

B
Figure 31.13. The 1500 method of calculating heart rate on an ECG. (From Lipman, BC, and Cascio, T: ECG Assessment and Interpretation. FA Davis, Philadelphia,
3. To interpret the rhythm, the following systematic approach is recommended: Record the
A. Perform a general inspection of the rhythm strip. Look for possible artifacts.
B. Identify specific waves and intervals.
C. Is the rhythm regular or irregular? Using calipers, check the distance between R waves.
A regular rhythm should have the same distance (within two small boxes) between all R
waves. The conduction ratio is the number of P waves for each QRS complex.
D. Calculate the rate.
E. P waves: Are they present? What is their shape? Are they all alike? Is each followed by a
QRS? What is the PR interval?
F. QRS: Are they present? What is their shape? Are they all alike? What is the QRS width?
G. Are all the RR intervals the same?
H. ST segment: Is it baseline? Is it elevated or depressed?
I. T wave: Is it normal? Is it inverted?
J. Interpret the rhythm.
Working with practice tracings from your instructor, use the preceding method to interpret
the rate and rhythm for each. Attach the strips and results to your laboratory report.
R E FE R E N C E S
1. Wilkins, RL, Dexter, JR, and Heuer, AJ: Clinical Assessment in Respiratory Care, ed. 6. Elsevier, St. Louis, 2010.
2. American Association for Respiratory Care: AARC clinical practice guideline: In-hospital transport of the mechanically ventilated patient,
2002 revision and update. Respir Care 47: 721–723, 2002.
3. American Association for Respiratory Care: AARC clinical practice guideline: Resuscitation and defibrillation in the health care setting,
2004 revision and update. Respir Care 49: 1085–1099, 2004.
4. Sharek, PJ, et al: Effect of a rapid response team on hospital-wide mortality and code rates outside the ICU in a children’s hospital. JAMA
19:2267–2274, 2007.
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2679_Ch31_529-552.indd 538 07/02/13 4:47 PM
Laboratory Report
CHAPTER 31: ELECTROCARDIOGRAPHY
Name: Date:
Data Collection
EXERCISE 31.1 Cardiac Anatomy
Label the heart diagram in Figure 31.1.
A. _____________________________________________ B. ________________________________________________
C. _____________________________________________ D. ________________________________________________
E. _____________________________________________ F. ________________________________________________
G. _____________________________________________ H. ________________________________________________
I. _____________________________________________ J. ________________________________________________
K. _____________________________________________ L. ________________________________________________
M. _____________________________________________ N. ________________________________________________
O. _____________________________________________ P. ________________________________________________
Q. _____________________________________________ R. ________________________________________________
S. _____________________________________________ T. ________________________________________________
U. _____________________________________________ V. ________________________________________________
Label the conduction system in Figure 31.2.
A. _____________________________________________ B. ________________________________________________
C. _____________________________________________ D. ________________________________________________
E. _____________________________________________ F. ________________________________________________
G. _____________________________________________ H. ________________________________________________
I. _____________________________________________ J. ________________________________________________
2679_Ch31_529-552.indd 539 07/02/13 4:47 PM

EXERCISE 31.2 Identification of Electrocardiograph Machine Controls
Type of machine used: _____________________________________
Controls identified: _____________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
EXERCISE 31.3 Preparation and Attachment of Limb Leads
Attach the ECG tracing or copy to the laboratory report.
EXERCISE 31.4 Preparation and Attachment of Precordial (Chest) Leads
E XE RCI SE 3 1 .4 . 1 S TA ND A R D C H E S T L E A D S
Attach the ECG tracing or copy to the laboratory report.
EXERCISE 31.5 Electrocardiograph Artifact
E XE RCI SE 3 1 .5 . 1 ID E NT IFIC AT IO N O F A R T IFACT
Figure 31.7: ______________________________________________
Figure 31.8: ______________________________________________
Figure 31.9: ______________________________________________
Figure 31.10: _____________________________________________
E XE RCI SE 3 1 .5 . 2 S IMU L AT IO N O F A R T IFA C T
Tracings or observations: ___________________________________
Deep breathing: __________________________________________
Tensing of muscles: _______________________________________
Limb movement: __________________________________________
Touching the metal bed rails or ECG machine or plugging in electrical device (record method used): _____________________________
Loosening the right electrode lead: ___________________________
Loosening the left electrode lead: ____________________________
Reversal of the right and left electrode leads: ___________________
Replacement of the electrode without a gel or alcohol swab: _______
2679_Ch31_529-552.indd 540 07/02/13 4:47 PM

EXERCISE 31.7 Rate and Rhythm Interpretation
Using the tracings obtained from Exercise 31.3 or 31.4, perform the following:
1. Calculate the heart rate by all three methods. Show your work for each.
6-second strip: _________________________________________
RR method: ____________________________________________
1500 method: __________________________________________
2. Measure the PR interval.
Number of small boxes: __________________________________
PR interval duration in seconds: ___________________________
Normal PR interval: _____________________________________
3. Interpret the rhythm.
General inspection:______________________________________
Is the rhythm regular or irregular? __________________________
Calculate the rate: ______________________________________
Are all the P waves upright? ______________________________
Are the P waves alike? __________________________________
Is there a P wave for every QRS? __________________________
What is the PR interval? __________________________________
Evaluate the QRS complexes. Are they all alike? _______________
Is there a QRS for every P? _______________________________
Measure the QRS width. Number of small boxes: ______________
QRS width in seconds: ___________________________________
Normal QRS width: ______________________________________
Are all the RR intervals the same? __________________________
Is the ST segment baseline, elevated, or depressed? ___________
Is the T wave normal? Is it inverted? ________________________
Interpretation: _________________________________________
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Interpret the following ECG rhythm tracings:
1. A patient was found unconscious at home. Paramedics sent the strip via telemetry (Fig. 31.14).
Figure 31.14. Rhythm strip 1. (From Brown, KR, and Jacobson, S: Mastering Dysrhythmias: A Problem-Solving Guide. FA Davis, Philadelphia, 1988, p. 25, with
permission.)
A. Rate:
B. Rhythm: regular or irregular?
C. P waves: present, shape, all alike, followed by normal QRS?
D. PR interval:
E. QRS: present, shape, all alike?
F. QRS width:
G. ST segment: baseline, elevated, or depressed?
H. T wave: normal or inverted?
I. Identification of rhythm:
J. Pharmacological treatment of choice or other treatment (if applicable):
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2. An 84-year-old man was seen in the doctor’s office complaining of dizziness and light-headedness (Fig. 31.15).
Figure 31.15. Rhythm strip 2. (From Jones, SA: ECG Success: Exercises in ECG Interpretation. FA Davis, Philadelphia, PA 2008, ECG 3-1, p. 23. With
permission.)
A. Rate:
D. PR interval:
F. QRS width:
J. Pharmacological treatment of choice (if applicable):
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3. A patient with a history of COPD being treated for an acute exacerbation began complaining of palpitations
(Fig. 31.16).
permission.)
A. Rate:
D. PR interval:
F. QRS width:
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C H A P T E R 31 | E LE C TR OC AR DIOGR AP HY • 545
4. A 64-year-old woman was brought to the emergency department with a chief complaint of heaviness in the chest and
tightness in the back and left shoulder (Fig. 31.17).
Figure 31.17. Rhythm strip 4. (From Jones, SA: ECG Success: Exercises in ECG Interpretation. FA Davis, Philadelphia, PA 2008, ECG 11-14, p. 91.
With permission.)
A. Rate:
D. PR interval:
F. QRS width:
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5. Figure 31.18 was obtained several days later on the patient in Question 4.
Figure 31.18. Rhythm strip 5. (From Jones, SA: ECG Success: Exercises in ECG Interpretation. FA Davis, Philadelphia, PA 2008, ECG 11-12, p. 90.
With permission.)
A. Rate:
B. P waves: present, shape, all alike, followed by normal QRS?
C. PR interval:
D. QRS: present, shape, all alike?
E. QRS width:
F. ST segment: baseline, elevated, or depressed?
G. T wave: normal or inverted?
H. Rhythm: regular or irregular?
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6. You enter a patient’s room to perform an arterial blood gas. During preparation for the procedure, you notice the
rhythm shown in Figure 31.19 on the ECG monitor.
permission.)
A. What should you do first?
B. You have determined that the patient has no respirations or pulse. What would your next action(s) be?
C. Once advanced life support emergency equipment is available, what should be done first to treat this rhythm?
D. The patient’s pulse and blood pressure have returned and the rhythm shown in Figure 31.20 is noted on the ECG
monitor. What is the most indicated pharmacological treatment for this rhythm?
permission.)
7. Why does the 12-lead ECG have only 10 electrode leads that are placed on the patient?
8. In atrial fibrillation, why is the atrial rate significantly higher than the ventricular rate?
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9. When treating a patient with atrial fibrillation, describe the two methods of cardioversion and when each should
be used.
10. Describe the differences and hallmark signs seen in the ECG patterns of first-degree, second-degree (Mobitz I and II),
and third-degree AV blocks.
11. Why do atrial rhythms decrease cardiac output?
12. The RCP is performing CPT on a cardiac patient. The patient begins exhibiting ventricular fibrillation on the cardiac
monitor. The RCP notes that the patient is conscious and has a palpable pulse. What is the most likely explanation for
this rhythm?
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STUDENT: DATE:
ELECTROCARDIOGRAPHY
PERFORMANCE LEVEL
PERFORMANCE RATING
Performance Level:
NA = Not applicable
Performance Rating:

2. Obtains the ECG machine, electrodes, gel, gauze, and paper; ensures that the machine has sufficient paper and supplies available

4. Ensures patient comfort and respects patient privacy and modesty
5. Places the patient appropriately in a supine or semi-Fowler’s position; instructs the patient to relax completely
6. Has the patient remove all jewelry or metal
7. Applies clean limb electrodes to muscular areas of the patient’s arms and legs; placement is in a similar location on both arms and legs
8. Places the chest leads in the proper location:
A. V1: 4th intercostal space right sternal margin D. V4: Fifth intercostal space, left midclavicular line
B. V2: 4th intercostal space left sternal margin E. V5: Fifth intercostal space, left anterior axillary line
C. V3: Midway between V2 and V4 F. V6: Sixth intercostal space, left midaxillary line
9. Calibrates the machine; runs the test strip
10. Inspects the rhythm strip for:
A. Wandering baseline D. Disconnected lead or intermittent loss of signal
B. 60-cycle artifact E. Incorrect lead placement
C. Muscle tremor artifact
11. Runs a complete 12-lead ECG
12. Scans the cardiogram for any major dysrhythmias
13. Measures, analyzes, or interprets:
A. Rhythm F. ST segment
B. Rate G. T wave
C. P wave appearance H. QT interval
D. PR interval I. Interprets ECG results
E. QRS complex appearance and width
FOLLOW-UP
15. Maintains the patient’s privacy
16. Removes the electrodes and cleans the electrode sites
17. Cleans the electrodes and the machine
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PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch31_529-552.indd 550 07/02/13 4:47 PM


STUDENT: DATE:
ECG INTERPRETATION
PERFORMANCE LEVEL
PERFORMANCE RATING
Performance Level:
NA = Not applicable
Performance Rating:
1. Obtains an ECG rhythm strip

2. Analyzes the strip for the presence of artifact
3. Differentiates the artifact from the actual ECG tracing
4. Calculates the heart rate by the 6-second, RR, or box counting method
5. Determines regularity by analyzing the R wave distance with calipers
6. Evaluates the presence and shape of P waves
7. Calculates the PR interval
8. Evaluates the QRS width
9. Evaluates the ST segment for elevation or depression
10. Evaluates the T wave for inversion
11. Identifies any ectopic beats
12. Correctly interprets the rate and rhythm
2679_Ch31_529-552.indd 551 07/02/13 4:47 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
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CHAPTER Hemodynamic
Monitoring
INTRODUCTION The role of the respiratory care practitioner (RCP) has evolved greatly over the past
several decades. The responsibilities of the RCP have progressed from obtaining basic
vital signs to the performance of technologically advanced hemodynamic and laboratory
techniques. In particular, major advancements have been made in the evaluation of the
cardiovascular system and the efficiency of oxygen delivery in the care of the critically
ill.1 Application of physiological principles and the interpretation of the data obtained
from hemodynamic monitoring aid in the care of the critically ill, enhance patient-
ventilator management, and improve clinical outcomes.2 Although the involvement of the
respiratory therapist with hemodynamic monitoring varies from facility to facility,
mastering the use of this equipment—including setup, troubleshooting, and
interpretation of results—helps make the RCP an indispensable member of the patient
care team. In addition, the National Board for Respiratory Care recognizes that RCPs
must demonstrate a basic competency in this area, particularly for those seeking the
advanced (RRT) level credential.
It should be noted that although there are noninvasive methods for hemodynamic
monitoring, this chapter focuses on invasive techniques that the RCP will most likely
encounter.3
OBJECTIVES 1. Practice communication skills needed for the instruction of patients during hemodynamic
Upon completion of this monitoring.
chapter, you will be able to: 2. Identify the components of a pulmonary artery catheter.
3. Identify the proper port for mixed venous blood sampling on a pulmonary artery catheter.
4. Select, assemble, and calibrate the equipment required for a fluid-filled monitoring system.
5. Calibrate a pressure transducer.
6. Simulate the procedure for obtaining a cardiac output using the thermodilution method.
7. Identify central venous, right ventricle, pulmonary artery, and pulmonary capillary wedge
waveforms.
8. Identify and correct problems with a fluid-filled monitoring system.
9. Practice the calculations to obtain derived hemodynamic data: body surface area, Fick
equation, mean arterial pressure, mean pulmonary artery pressure, cardiac index, various
shunt equations, systemic vascular resistance, and pulmonary vascular resistance.
10. Practice documentation and reporting of hemodynamic data collected.
553
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KEY TERMS
body surface area pulmonary capillary systemic vascular
cardiac index wedge pressure resistance
cardiac output pulmonary vascular viscosity
central venous pressure resistance
phlebostatic axis shunt
Exercises
F 10-mL syringes (five) F IV tubing (high-pressure)
F Alcohol prep pads F Medical scale
F Basin F Medication label
F DuBois body surface area chart F Mercury manometer with inflation bulb
F Equipment manual F Microdrip chamber
F Female caps F Pressure and cardiac output monitor
F Hemodynamic simulator (if available) F Pressure transducer
F Heparin F Quadruple-lumen or triple-lumen pulmonary
F Ice artery catheter
F Inflatable pressure bag or pressure infuser F Sterile normal saline
F Intraflow or flush device F T-connectors
F IV pole F Three-way stopcocks
F IV saline solution (1-L bag) F Tuberculin syringe
EXERCISE 32.1 IDENTIFICATION OF THE COMPONENTS OF A FLOW-DIRECTED

PULMONARY ARTERY CATHETER
1. Select a pulmonary artery catheter as shown in Figure 32.1. Identify the components on your
laboratory report.
F Thermistor connection
F Balloon inflation port
F Proximal port
F Distal port
F Thermistor opening
F Balloon
F Distal opening
F Centimeter markings
F Proximal opening
F Extra injection port
2. Using a tuberculin syringe, inflate the balloon with 0.5 mL of air. Overinflation of the
balloon will cause it to rupture. This is expensive in the laboratory setting and dangerous in
the clinical setting.
3. Feel the balloon.
4. Deflate the balloon.
5. Identify the port used for mixed venous blood sampling and record it on your laboratory
report.
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C H A P T E R 32 | H E M O D Y NAM IC M ONITOR ING • 555
J B
I
D
F
C
H
E
Figure 32.1. The components of a flow-directed pulmonary artery catheter.
EXERCISE 32.2 ASSEMBLY AND CALIBRATION OF A FLUID-FILLED MONITORING

SYSTEM1
1. Gather the necessary equipment and assemble it as shown in Figure 32.2. Make sure your
handling of the equipment maintains the sterility of all ports. All ports should be capped
with female caps to avoid inadvertent contamination.
2. Simulate heparinizing the IV solution and label the bag. Use 10 mg of a 1% solution of
heparin per 500 mL. Record on your laboratory report how much heparin is needed for the
size IV solution bag used in your setup.
3. Insert the microdrip chamber spike and IV tubing into the bag.
4. Squeeze all the air out of the IV bag.
5. Gravity-fill the tubing and transducer assembly.
6. Inspect for the presence of air bubbles. Remove any air bubbles found.
7. Place the IV bag into the inflatable pressure bag or pressure infuser.
8. Inflate the pressure bag or infuser to 300 mm Hg.
9. Turn on the pressure monitor and allow 5 to 10 minutes for warm-up.
10. Zero the monitor and transducer according to the manufacturer’s instructions, as shown in
Figure 32.3.
11. Close the system by closing the stopcock to all ports.
12. Connect the proximal port of the catheter to the IV tubing.
13. The completed setup is shown in Figure 32.4.
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A B C
Figure 32.2. The components of a fluid-filled monitoring

system. (A) IV flush solution; (B) Pressurized IV flush
solution; (C) Flush assembly; (D) Removal of air from
tubing and stop cock. D
Stopcock open to atmosphere Midaxillary line Stopcock open to atmosphere
A B
Figure 32.3. Zero the pressure transducer by placing the stopcock level with the midaxillary line. (Adapted from Gardner, RM, and
Hollingsworth, KW: Optimizing the electrocardiogram and pressure monitoring. Crit Care Med 14:651, 1986, with permission.)
2679_Ch32_553-576.indd 556 07/02/13 4:47 PM

Balloon inflation
Normal saline port
with heparin and
pressure infusor
Proximal
Microdrip (RA) port
chamber
300
mm Hg
Proximal
(PA) port
Stopcock
(single)
High-pressure
tubing
Thermistor
outlet
Three-way
stopcock
Continuous
flush device
Transducer
dome
Fast-flush
valve
Transducer
Monitor console
Figure 32.4. Completed assembly of a fluid-filled monitoring system.
EXERCISE 32.3 TRANSDUCER CALIBRATION
1. Select and assemble the equipment as shown in Figure 32.5.

2. Open the stopcock to ensure communication between the manometer and the pressure
monitor.
3. Inflate the manometer to 90 mm Hg by squeezing the bulb.
4. Observe the pressure monitor and record the pressure reading on your laboratory report.
5. Disassemble the equipment.
2679_Ch32_553-576.indd 557 07/02/13 4:47 PM

Manometer
Pressure monitor console
Stopcock open T
Stopcock closed to manometer connector
and disconnected
from patient
Pressure
release valve
Reusable
pressure
transducer
Air bulb
Figure 32.5. Assembly of a pressure transducer and manometer for transducer calibration.
2679_Ch32_553-576.indd 558 07/02/13 4:47 PM

EXERCISE 32.4 IDENTIFICATION OF PRESSURE WAVEFORMS
1. Identify the pressure waveforms in Figures 32.6, 32.7, 32.8, and 32.9 on your laboratory
report.
2. Common problems associated with a fluid-filled monitoring system are shown in
Figure 32.10. Using a simulator (if available), generate and identify the following problem
waveforms: overdampened system, underdampened sytem, flush, and catheter whip. Print
out (if possible) the waveforms associated with these problems and attach them to your
laboratory report, or draw them on a separate sheet.
3. List five causes of an overdampened system. Record your answers on your lab report.
4. List five causes of an underdampened system. Record your answers on your lab report.
5. What happens to the pressure waveform when the system is flushed? Record your answer on
your lab report.
6. What is catheter whip and what are the causes? Record your answer on your lab report.
Figure 32.6. Waveform A.
Figure 32.7. Waveform B.
Figure 32.8. Waveform C.
Figure 32.9. Waveform D.
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Figure 32.10. Problem identification for a fluid-filled monitoring system. (Adapted from Darovic, GO: Hemodynamic
Monitoring: Invasive and Noninvasive Clinical Application, ed. 2. WB Saunders, Philadelphia, 1995, p. 312, with permission.)
EXERCISE 32.5 THERMODILUTION CARDIAC OUTPUT DETERMINATION
This exercise simulates the 1. Wash your hands and apply standard precautions and transmission-based isolation
preparation of materials procedures as appropriate.
necessary to obtain a cardiac 2. Explain the purpose of the procedure to the “patient.”
output. 3. Prepare an ice/slush solution on the basin. Be sure to maintain the sterility of all solutions,
ports, and connectors.
4. Make sure that the cardiac output pressure monitor is turned on and properly calibrated
and zeroed according to the instructions in the manual.
5. Connect the temperature probe to the monitor.
6. Fill four 10-mL syringes with sterile normal saline. Be sure to maintain sterility. Inspect the
syringes and ensure that they are free from any air bubbles.
7. Insert the probe into one of the syringes to verify the injectate temperature.
8. Place the syringes in the ice/slush bath.
9. Ensure that the thermistor port of the catheter is connected to the monitor. The system
should be similar to Figure 32.11.
10. Position the “patient” in the supine position (not elevated more than 30°).
11. Verify the catheter position by identifying the proper pressure waveform for the pulmonary
artery.
12. Record the temperature of the injectate solution by pressing the appropriate key on the face
of the monitor. The temperature should be between 0°C and 4°C.
13. Take one of the injectate syringes and connect it to the proximal port of the catheter.
A three-way stopcock may be used.
14. Press the “Start” key on the monitor.
15. Steadily and rapidly inject the 10-mL solution. The injection should take no longer than
4 seconds. Observe the waveform produced.
16. Observe the cardiac output reading.
17. Repeat the procedure at intervals of 90 seconds until three readings have been obtained.
The readings should be within 10% of each other. If they are not, a technical error may
have occurred. Using the fourth syringe, obtain another cardiac output. Record all readings
18. Average the three readings to report the cardiac output and record the results on your
laboratory report.
19. Ensure the “patient’s” comfort after the procedure.
20. Clean the area and discard any medical waste in the appropriate containers.
21. Remove and properly dispose of any PPE. Wash your hands.
22. Record any data and your observations on your laboratory report.
2679_Ch32_553-576.indd 560 07/02/13 4:47 PM

Distal
lumen
Thermistor
Proximal
Balloon Injectate
injectate port Distal probe
lumen hub Balloon connector
inflation
valve
Cardiac output computer

Thermistor
connector
Syringe for
Proximal
injection
injectate hub
To pressure
monitoring Check valve
tubing
Temperature
probe
Cooling canister
and coil
Figure 32.11. System for obtaining a thermodilution cardiac output.
EXERCISE 32.6 HEMODYNAMIC CALCULATIONS
Record the calculation results on your laboratory report. Normal hemodynamic data are
provided in Table 32.1.
Table 32.1 Normal Adult Hemo-

Cardiac output 4–8 Lpm
dynamic Data*
Cardiac index 2.5–4.2 Lpm/m2
Arterial blood pressure 100–140/60–90 mm Hg
Central venous pressure 2–6 mm Hg
Right ventricular pressure 15–25/0–8 mm Hg
Pulmonary artery pressure 15–25/6–12 mm Hg
Mean pulmonary artery pressure 10-20 mmHg
Pulmonary wedge pressure 4–12 mm Hg
Percent shunt 3%–5%
Systemic vascular resistance 770–1,500 dyne·sec/cm5
Pulmonary vascular resistance 150–250 dyne·sec/cm5
*It should be noted that normal values may vary somewhat from text to text or from institution to institution.
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EXERCISE 3 2 .6 .1 MEAN AR TER IAL PR E S S U R E

Calculate the mean arterial pressure (MAP) using the following formula:
MAP = systolic + 2(diastolic) / 3

1. Systolic = 120 mm Hg, diastolic = 80 mm Hg
EXERCISE 3 2 .6 .2 MEAN PULMON AR Y A R T E R Y P R E S S U R E

Calculate the mean pulmonary artery pressure (MPAP) using the following formula:
MPAP = PA systolic + 2(PA diastolic)/3

EXERCISE 3 2 .6 .3 C ARDIAC OUTPUT U S I N G T H E FI C K E Q U AT I O N

Calculate the cardiac output for the following data using the Fick equation:
Cardiac output = Oxygen consumption / C(a–v)o2

Pao2 = 85 mm Hg Paco2 = 40 mm Hg
Sao2 = 93% Hb = 14 g/dL
Pvo2 = 38 mm Hg Pvco2 = 44 mm Hg
Svo2 = 68% Fio2 = 0.50
Oxygen consumption = 260 mL/min
EXERCISE 3 2 .6 .4 C ARDIAC IN DEX

1. Using your laboratory partner as the patient, obtain your partner’s height and weight.
Record this data on your laboratory report.
2. Using the DuBois body surface area (BSA) chart in Figure 32.12, obtain your partner’s body
surface area. Record it on your laboratory report.
3. Calculate BSA using the following formula. Record the BSA on your laboratory report.
BSA = (4 × weight in kg) + 7 / Weight in kg + 90
4. Assuming a cardiac output of 50 L, calculate the cardiac index using the following formula.
Record it on your laboratory report.
Cardiac index = Cardiac output / Body surface area
EXERCISE 3 2 .6 .5 S YSTEMIC AN D PU LMO N A R Y VA S C U LA R R E S I S TA N C E

Using the following data and formulas, calculate systemic vascular resistance (SVR) and pulmo-
nary vascular resistance (PVR). Record this data in your laboratory report.
SVR dyne·sec/cm5 = Mean arterial pressure–CVP / cardiac output × 80

PVR dyne·sec/cm5 = Mean PAP–PWP / cardiac output × 80
Blood pressure = 108/60 mm Hg
PAP = 24/12 mm Hg
PWP = 8 mm Hg
CVP = 0 mm Hg
Cardiac output (CO): Use the answer from Exercise 32.6.2.
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Figure 32.12. DuBois body surface area chart. (Adapted from DuBois, EF: Basal Metabolism in Health and Disease. Philadelphia, Lea & Febiger, 1936.)
2679_Ch32_553-576.indd 563 07/02/13 4:47 PM

EXERCISE 3 2 .6 .6 S HUN T CALCULATI O N

Using the following data, calculate the percent shunt using all three formulas. Record and com-
pare the results on your laboratory report.
Classic Shunt Formula
Percent shunt = Cco2–Cao2/Cco2–Cvo2 × 100

Cco2 = 1.0 (1.34 × Hb) + (0.003 × PAO2)
Modified Estimated Shunt Equation: QS/QT
(PAO2–PaO2) × 0.003/(CaO2–CvO2) + [(PAO2–PAO2) × 0.003]

Can use 5 for C(a–v)O2 in stable individuals or 3.5 in critically ill.
Estimated Shunt
AaDo2/5 on room air Pao2 = 485 mm Hg

Paco2 = 35 mm Hg Sao2 = 99%
Hb = 12 g/dL Pvo2 = 380 mm Hg
Pv = 47 mm Hg Svo2 = 99%
Fio2 = 1
RE F E RE N CE S
1. Darovic, GO: Hemodynamic Monitoring: Invasive and Noninvasive Clinical Application, ed. 3. Elsevier, St. Louis, 2002.
2. Hadian, M, and Pinsky, MR: Functional hemodynamic monitoring. Curr Opin Crit Care 13:318–323, 2007.
3. Chan, JS, Segara, D, and Nair, P: Measurement of cardiac output with a non-invasive continuous wave Doppler device versus the
pulmonary artery catheter: A comparative study. Crit Care Resusc 8:309–314, 2006.
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Laboratory Report
CHAPTER 32: HEMODYN AMIC MONITORING
Name: Date:
Data Collection
EXERCISE 32.1 Identification of the Components of a Flow-Directed Pulmonary Artery
Catheter
A: _________________________________________________________________________________________________________
B: _________________________________________________________________________________________________________
C: _________________________________________________________________________________________________________
D: _________________________________________________________________________________________________________
E: _________________________________________________________________________________________________________
F: _________________________________________________________________________________________________________
G : _________________________________________________________________________________________________________
H: _________________________________________________________________________________________________________
I: _________________________________________________________________________________________________________
J: _________________________________________________________________________________________________________
Blood sampling port: ___________________________________________________________________________________________
EXERCISE 32.2 Assembly and Calibration of a Fluid-Filled Monitoring System
Amount of heparin used (Show your work): _________________________________________________________________________
____________________________________________________________________________________________________________
EXERCISE 32.3 Transducer Calibration
Pressure reading: _____________________________________________________________________________________________
EXERCISE 32.4 Identification of Pressure Waveforms
Figure 32.6: __________________________________________________________________________________________________
Figure 32.7: __________________________________________________________________________________________________
Figure 32.8: __________________________________________________________________________________________________
Figure 32.9: __________________________________________________________________________________________________
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List five causes for an overdampened system:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
List five causes for an underdampened system:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
What happens to the pressure waveform when the system is flushed?
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
What is catheter whip and what are the causes?
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
EXERCISE 32.5 Thermodilution Cardiac Output Determination
CO 1: _______________________________________________________________________________________________________
CO 2: _______________________________________________________________________________________________________
CO 3: _______________________________________________________________________________________________________
CO 4: _______________________________________________________________________________________________________
Average CO (Show your work): ___________________________________________________________________________________
Observations: ________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
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EXERCISE 32.6 Hemodynamic Calculations
Show all of your work.
E X E R C IS E 32 . 6. 1 ME A N A R T E RIAL PRESSURE
1. MAP = __________________________________________________________________________________________________
2. MAP = __________________________________________________________________________________________________
3. MAP = __________________________________________________________________________________________________
E X E R C IS E 32 . 6. 2 ME A N P U L MON ARY ARTERY PRESSURE
1. MPAP = _________________________________________________________________________________________________
2. MPAP = _________________________________________________________________________________________________
3. MPAP = _________________________________________________________________________________________________
E X E R C IS E 32 . 6. 3 C A R D IA C O UTPUT USIN G THE F ICK EQUATION
Cardiac output: _______________________________________________________________________________________________
E X E R C IS E 32 . 6. 4 C A R D IA C IN DEX
Partner’s height: ______________________________________________________________________________________________
Partner’s weight: _____________________________________________________________________________________________
DuBois BSA: _________________________________________________________________________________________________
Calculated BSA: ______________________________________________________________________________________________
Cardiac index: ________________________________________________________________________________________________
E X E R C IS E 32 . 6. 5 S Y S T E M IC AN D PUL MON ARY VASCUL AR RESISTAN CE
Mean arterial pressure: ________________________________________________________________________________________
SVR dyne·sec/cm5: ____________________________________________________________________________________________
PVR dyne·sec/cm5: ____________________________________________________________________________________________
E X E R C IS E 3 2 . 6. 6 S H U N T C A L CUL ATION
CcO2: _______________________________________________________________________________________________________
CaO2: _______________________________________________________________________________________________________
Cvo2: _______________________________________________________________________________________________________
Percent shunt (classic): ________________________________________________________________________________________
Percent shunt (modified): _______________________________________________________________________________________
Percent shunt (estimated): ______________________________________________________________________________________
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1. For each of the pressure tracings shown in Figures 32.13 through 32.16, identify and interpret the waveforms for
channels 1 (ECG tracing) and 2 (hemodynamic tracing). Identify what is being monitored in channel 3. If the tracing
indicates a malfunction, state what corrective action(s) would be needed. Correlate the tracings with possible clinical
findings, and recommend any necessary therapeutic interventions, if possible.
Tracing A
Channel 1 ___________________________ Channel 2 ________________________ Channel 3 ______________________
Corrective action(s) needed, clinical findings, therapeutic interventions?
Figure 32.13. Tracing A.
Tracing B
Figure 32.14. Tracing B.
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C H A P T E R 32 | H E M O D YNAM IC M ONITOR ING • 569
Tracing C
Figure 32.15. Tracing C.
Tracing D
Figure 32.16. Tracing D.
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2. What is the cause of the dichrotic notch and on which pressure waveform can it be seen?
3. What would cause a large temperature change of the injectate to occur when using the flow-directed pulmonary artery
catheter to directly measure cardiac output by the thermodilution technique?
4. During what phase of the respiratory cycle do you take the pulmonary wedge pressure reading? Why?
5. When measuring the pulmonary wedge pressure of a ventilated patient receiving PEEP, should you take the patient off
the ventilator for the reading? Why or why not?
6. A patient in the intensive care unit is being monitored with a flow-directed pulmonary artery catheter. The physician
asks for a pulmonary wedge pressure to be performed. You inflate the balloon with 1.5 mL of air, but following bal-
loon inflation you do not see the wedge tracing on the manometer. What might cause this problem?
7. At what point during the insertion of a flow-directed pulmonary artery catheter is the balloon inflated? What is the
benefit of balloon inflation during insertion?
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8. What is the danger of prolonged balloon inflation when obtaining a pulmonary wedge pressure measurement?
Case Studies
Interpret the following hemodynamic profiles:
9. A 63-year-old female with a history of MI is admitted to the emergency department. The patient has a chief complaint
of chest pain and shortness of breath. A flow-directed pulmonary artery catheter, arterial line, and Foley catheter are
inserted and reveal the following results:
HR = 110 bpm CVP = 5 mm Hg

BP = 100/60 mm Hg PAP = 55/40 mm Hg
CO = 2.8 L/min PWP = 32 mm Hg
Calculate the following parameters for A, B, C, and D and answer E and F (Show your work):
A. MAP: _________________________________________
B. MPAP: ________________________________________
C. PVR: __________________________________________
D. SVR: __________________________________________
E. Interpretation of the data: __________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
F. Pharmacological treatment of choice or other treatment (if applicable): ___________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
10. A 72-year-old male is transferred to the emergency department from a long-term care facility. The patient has a chief
complaint of chest pain. The patient is pale, dyspneic, and has increased skin turgor. He is given furosemide to increase
urine output. A flow-directed pulmonary artery catheter is inserted and reveals the following results:

BP = 196/65 mm Hg PAP = 20/5 mm Hg
A. MAP: _________________________________________
B. MPAP: ________________________________________
C. PVR: __________________________________________
D. SVR: __________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
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11. A patient is brought to the open-heart unit after undergoing a coronary artery bypass graft. A flow-directed pulmonary
artery catheter, chest tube drainage system, and Foley catheter have been placed while the patient was in the operating
room. The patient is orally intubated and is being mechanically ventilated. Six hours postop, the following results are
obtained from the monitoring system:

BP = 62/40 mm Hg PAP = 40/16 mm Hg
A. MAP: _________________________________________
B. MPAP: ________________________________________
C. PVR: __________________________________________
D. SVR: __________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
2679_Ch32_553-576.indd 572 07/02/13 4:47 PM


STUDENT: DATE:
HEMODYNAMIC MEASUREMENTS
PERFORMANCE LEVEL
PERFORMANCE RATING
Evaluator: Setting:
Performance Level:
NA = Not applicable
Performance Rating:


3. Identifies the components of a Swan-Ganz catheter:
A. Inflation lumen port
B. Distal lumen port
C. Proximal lumen port
D. Thermistor connection
E. Proximal lumen orifice
F. Balloon
G. Distal orifice
4. Identifies the proper injectate site (proximal port)
5. Identifies pressure waves; states the normal pressure ranges for each:
A. CVP
B. RA
C. RV systolic
D. RV diastolic
E. PA systolic
F. PA diastolic
G. PAP mean
H. PWP
6. Corrects any malfunctions of the pressure measuring system
7. Records the cardiac output from the monitor for a minimum of three injections within 10%
8. Averages the three measurements
9. Interprets all data obtained
FOLLOW-UP
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PERFORMANCE RATING:

COGNITIVE DOMAIN
to modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch32_553-576.indd 574 07/02/13 4:47 PM


STUDENT: DATE:
SHUNT STUDIES
PERFORMANCE LEVEL
PERFORMANCE RATING
Evaluator: Setting:
Performance Level:
NA = Not applicable
Performance Rating:


3. Draws a mixed venous sample from the proximal port of the pulmonary artery catheter
4. Draws an arterial blood gas sample
5. Analyzes and records the results of both samples
6. Calculates the following values:
PAO2
PAADO2
a/A ratio
Oxygenation ratio
CaO2
CvO2
Cardiac output
Percent shunt
MAP
SVR
FIO2 needed for a desired PaO2
7. Interprets results
FOLLOW-UP
2679_Ch32_553-576.indd 575 07/02/13 4:47 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
to modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
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CHAPTER Phlebotomy
INTRODUCTION Phlebotomy1 is the act of drawing blood from a vein by incision or puncture to obtain a
sample for analysis and diagnosis. It has also been known as venesection or venipuncture.
Usually a 5 to 25 mL sample of blood is adequate, depending on what blood tests have
been requested. In many circumstances, a phlebotomist will draw the sample, although
nurses, doctors, and other medical staff (including respiratory care practitioners [RCPs])
are also trained to take blood. Phlebotomy is also the treatment of certain diseases such
as hemochromatosis and primary and secondary polycythemia.
Properly performed, phlebotomy does not carry the risk of mortality. It may cause
temporary pain and bleeding, but these are usually easily managed. On the other hand,
of phlebotomy device injuries, 33% are sustained by phlebotomists and 7% by clinical lab
workers; 11% occur while “disassembling” phlebotomy needles, and 22% during or after
disposal.2
OBJECTIVES 1. Demonstrate proper patient identification procedures.

Upon completion of this 2. Practice communication skills required for assessing the level of patient comprehension of the
chapter, you will be able to: procedure.
according to CDC guidelines.
4. Demonstrate proper selection and use of equipment necessary to perform a phlebotomy.
5. Demonstrate proper labeling procedures and completion of laboratory requisitions.
6. List preferred venous access sites and factors to consider in site selection.
7. Demonstrate the ability to differentiate between the feel of a vein, tendon, and artery.
8. List six areas to be avoided when performing venipuncture and the reasons for the
restrictions.
9. Demonstrate the use of the different collection methods.
10. Demonstrate the adequate preparation of a patient.
11. Demonstrate the adequate preparation of the venous access site.
12. Summarize the problems that may be encountered in accessing a vein, including the
procedure to follow when a specimen is not obtained.
13. Demonstrate the application of safety and infection control.
KEY TERMS
biohazard phlebotomist venesection
hemochromatosis sharps container venipuncture
needle Vacutainer®
577
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Exercises
F 5- or 10-mL safety syringes (may be used in F Holder/adapter
place of the evacuated collection tube for F Laboratory slip
special circumstances) F Personal protective equipment—goggles,
F Absorbent pad or towel safety shields, lab coats, masks
F Adhesive bandages/tape F Phlebotomy chairs with locking armrests
F Alcohol prep pads F Plastic vacuum blood-collecting tubes
F Artificial phlebotomy practice arms and F Povidone-iodine wipes/swabs
blocks F Sharps container
F Biohazard waste containers F Tourniquet
F Disposable adapters and needles of differing F Vacutainer® assembly with shielded, retract-
gauges able, or blunting needle
F Dry, sterile sponges
F Gauze sponges
EXERCISE 33.1 IDENTIFICATION OF VEINS
Identify the four veins illustrated in Figure 33.1 and record the answers on your laboratory report.
F Median basilic vein
F Basilic vein
F Median vein
F Cephalic vein
Figure 33.1. Identification of venipuncture sites.
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C H A P TER 33 | P HLEBOTOM Y • 579
EXERCISE 33.2 PREPARATION OF THE SUBJECT FOR PHLEBOTOMY
Scenario: Charles To perform this exercise, you will need a laboratory partner to simulate a patient and a phlebot-
Goldberg is a 55-year-old omy training device or venipuncture arm.
male with a history of atrial 1. Interview the “patient” and ask for the following:
fibrillation. A pacemaker was A. Use of medications and the last therapeutic drug monitoring
implanted 2 years ago and B. Last time that exercise or physical activity took place
he is currently taking C. The presence of stress or anxiety
warfarin once a day. D. If pregnant
2. Chart the answers on your laboratory report.
EXERCISE 33.3 PREPARATION FOR PHLEBOTOMY
1. Check the requisition form for requested tests, patient information, and any special
requirements or physician’s orders for the test to be obtained.
2. Wash your hands.
3. Gather equipment.
4. Open the sterile packages.
5. List the necessary equipment on your laboratory report.
EXERCISE 33.4 PHLEBOTOMY PROCEDURE
1. Identify the “patient.”

2. Introduce yourself and explain the procedure.
3. Don clean gloves.
4. Approach the “patient” in a friendly, calm manner. Provide for the “patient’s” comfort as
much as possible and gain the “patient’s” cooperation.
5. Position the “patient.” The “patient” should sit in a chair, lie down, or sit up in bed.
Hyperextend the “patient’s” arm.
6. Place the “patient’s” arm in a straight and independent position, if possible.
7. Select a suitable site for venipuncture.
8. Palpate and trace the path of the “patient’s” veins with the index finger. Arteries pulsate,
are more elastic, and have thick walls.
9. Place an absorbent pad or towel under the “patient’s” arm to prevent soiling the linen with
blood.
10. Place the equipment close to the work area.
11. Apply a tourniquet 3 to 4 inches above the selected puncture site. Tighten the tourniquet
and tell the “patient” to open and close his or her fist to increase blood flow to arm. Do
not leave the tourniquet on for more than 2 minutes.
12. Cleanse with antimicrobial wipe starting at the puncture site and moving in a circular
fashion about 2 inches away from the site.
13. Allow to air dry.
14. Hold the skin taut with your nondominant hand. Perform a venipuncture with the bevel of
the needle pointed up at a 15° to 30° angle (Fig. 33.2).
15. Lower the needle toward the “patient’s” skin after the needle has entered the vein.
16. Thread the needle along the path of the vein. Watch for backflow of blood in the syringe.
Figure 33.2. Proper bevel position for venipuncture.
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17. If a syringe is used, pull the plunger back gently and check for the placement of the needle
in the vein. If a Vacutainer® is used, insert the blood collection tube into a plastic holder
while holding the plastic adapter steady. Press the tube firmly into the short needle so that it
pierces the top of the tube. Blood should begin to spurt quickly into the tube until filled.
18. If placement is correct, instruct the “patient” to relax his or her fist, release the tourniquet,
wait a few seconds to allow fresh blood flow to flow into the vein, and then pull back
gently on the plunger if the syringe is used.
19. Fill the syringe to the desired amount.
20. Remove the needle from the vein, cover the venipuncture site with a sterile sponge, and
press firmly on the site for 2 to 3 minutes.
21. Do not remove the top from the laboratory tube. Place the needle straight through the top.
22. Gently eject the blood drawn inside of the tube. Do not allow the blood to foam or splash
because red blood cells can be destroyed.
23. Rotate the tube gently to mix the blood with the tube contents.
24. Label the tube promptly (Fig. 33.3). Write the “patient’s” name, ID number, date of birth,
sex, date and time of specimen collection, name of ordering physician, initials of the
phlebotomist, and source of specimen, if necessary (this information must be given when
requesting microbiology, cytology, fluid analysis, or other testing where analysis and
reporting is site specific.)
25. Check the “patient’s” venipuncture site for oozing.
26. Dispose of the shielded needle and syringe in a biohazard receptacle.
27. Do not bend, break, recap, or resheath needles to avoid accidental needle puncture or
splashing of contents. If you stick yourself with a contaminated needle:
A. Remove your gloves and dispose of them properly.
B. Squeeze the puncture site to promote bleeding.
C. Wash the area well with soap and water.
D. Record the “patient’s” name and ID number.
E. Follow the institution’s guidelines regarding treatment and follow-up.
NOTE: The use of prophylactic zidovudine following blood exposure to HIV has shown effec-
tiveness (about 79%) in preventing seroconversion.
29. Take the blood specimens to a designated station or laboratory according to hospital
procedure.
30. Summarize the procedure on your laboratory report.
Figure 33.3. Proper labeling of a blood tube.
EXERCISE 33.5 PHLEBOTOMY TROUBLESHOOTING
If an incomplete collection or 1. Change the position of the needle. Move it forward (it may not be in the lumen) (Fig. 33.4)
no blood is obtained: or move it backward (it may have penetrated too far) (Fig. 33.5).
Figure 33.4. Needle not advanced Figure 33.5. Needle advanced

into the vein. through the vein.
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C H A P T ER 33 | P HLEBOTOM Y • 581
2. Adjust the angle (the bevel may be against the vein wall) (Fig. 33.6).
3. Loosen the tourniquet (it may be obstructing blood flow).
4. Try another tube (there may be no vacuum in the one being used).
5. Reanchor the vein (veins sometimes roll away from the point of the needle and
puncture site).
If blood stops flowing into 1. The vein may have collapsed; resecure the tourniquet to increase venous filling. If this is not
the tube or syringe: successful, remove the needle, take care of the puncture site, and redraw (Fig. 33.7).
2. The needle may have pulled out of the vein when switching tubes. Hold the equipment firmly
and place your fingers against the “patient’s” arm, using the flange for leverage when
withdrawing and inserting tubes.
Problems Other Than an Incomplete Collection
1. A hematoma forms under the skin adjacent to the puncture site. Release the tourniquet
immediately and withdraw the needle. Apply firm pressure (Fig. 33.8).
2. The blood is bright red (arterial rather than venous). Apply firm pressure for more than
5 minutes (Fig. 33.9).
Figure 33.6. Needle positioned against

the vein wall. Figure 33.7. Vein collapse.
Figure 33.8. Hematoma formation. Figure 33.9. Arterial puncture.
R E FE R E N C E S
1. Ernst, DJ: Applied Phlebotomy, ed 1. Lippincott Williams & Wilkins, Philadelphia, 2005.
2. EPINet Multihospital Needlestick and Sharp-object Injury Data Report, 1993–2001; International Health Care Worker Safety Center,
University of Virginia Health System (90 healthcare facilities contributing data). (Report provided 5/22/03.)
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2679_Ch33_577-588.indd 582 07/02/13 4:47 PM
Laboratory Report
CHAPTER 33: PHLEBOTOMY
Name: Date:
Data Collection
EXERCISE 33.1 Identification of Veins
Label all veins in Figure 33.1.
A. _________________________________________________________________________________________________________
B. _________________________________________________________________________________________________________
C. _________________________________________________________________________________________________________
D. _________________________________________________________________________________________________________
EXERCISE 33.2 Preparation of the Subject for Phlebotomy
Scenario: Charles Goldberg
Document relevant patient history and explain its impact on the procedure:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
EXERCISE 33.3 Preparation for Phlebotomy
List the necessary equipment for venipuncture:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
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EXERCISE 33.4 Phlebotomy Procedure
Summarize in chronological order the most important steps in performing a venipuncture.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
EXERCISE 33.5 Phlebotomy Troubleshooting
Identify the situations illustrated in Figure 33.10 and describe the corrective action for each.
A. _________________________________________________________________________________________________________
B. _________________________________________________________________________________________________________
C. _________________________________________________________________________________________________________
D. _________________________________________________________________________________________________________
E. _________________________________________________________________________________________________________
F. _________________________________________________________________________________________________________
A B C
D E F
Figure 33.10. Troubleshooting and correcting common phlebotomy problems.
2679_Ch33_577-588.indd 584 07/02/13 4:47 PM


1. You are a RCP working in the emergency department. You are asked to perform a venipuncture on a patient who has
previously suffered burns to both arms and has extensive scarring. How would you suggest the venipuncture be
performed on this patient?
2. When inspecting a patient’s arm for venipuncture, you notice that there are multiple hematomas on both extremities.
How should you draw the specimen?
3. A patient in the ICU is receiving a blood transfusion intravenously in the right arm. The left arm has IV fluids being
administered. What is the procedure for drawing a venipuncture when an IV is being given to both extremities?
4. A patient who is postop for a left PICC line requires a venipuncture. How should the procedure be done?
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STUDENT: DATE:
VENIPUNCTURE
PERFORMANCE LEVEL
PERFORMANCE RATING
Evaluator: Setting:
Performance Level:
NA = Not applicable
Performance Rating:
Two or more errors of commission or omission of mandatory or essential performance elements will terminate the procedure,
and require additional practice and/or remediation and reevaluation. Student is responsible for obtaining additional evaluation
forms as needed from the Director of Clinical Education (DCE).


3. Selects the proper blood tubes based on laboratory policy and procedure
4. Hyperextends the patient’s arm in a straight and independent position
5. Selects a suitable site for the puncture by palpating and tracing the patient’s veins
6. Applies the tourniquet 3–4 inches above the puncture site
7. Tightens the tourniquet and asks the patient to make a fist
8. Cleanses the puncture site with an antimicrobial swab in a circular fashion, moving 2 inches away from the puncture site
9. Holds the patient’s skin taut with the nondominant hand
10. Inserts the needle at a 15°–30° angle with the bevel up
11. Threads the needle into the patient’s vein and observes for a backflow of blood into the needle or syringe
12. If a syringe is used, pulls back on the plunger and fills it to the proper amount
13. If a Vacutainer® is used, puts the blood tube into the plastic holder and fills it to the proper amount
14. If blood is not obtained, withdraws the needle to below the surface of the skin and repositions the needle
15. Removes the needle after the blood sample is obtained and compresses the puncture site for at least 2 to 3 minutes with a sterile gauze
16. Transfers the blood from the syringe to a blood tube
17. Gently mixes the blood in the tube
18. Assesses the puncture site for active bleeding or oozing
19. Applies an adhesive bandage
20. Labels the blood tube properly with the patient’s name and ID number
21. Disposes of all sharps properly
22. Delivers the sample to the designated station or laboratory
FOLLOW-UP
2679_Ch33_577-588.indd 587 07/02/13 4:47 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
to modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
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CHAPTER Intravenous
Insertion and
Maintenance
INTRODUCTION An intravenous (IV) catheter is introduced through the skin into a vein for the
administration of drugs or fluids. IV catheters are indispensable in medical practice
for providing necessary vascular access. In most institutions, the nurse is responsible
for the initiation and regulation of peripheral intravenous infusion. As the profession of
the respiratory care practitioner (RCP) expands toward nontraditional roles, however,
it is vital that RCPs incorporate new competencies into their scope of practice.1 It is
important for the RCP to understand the techniques for the insertion and maintenance of
IV catheters while ensuring minimal risk for local and systemic infectious complications.
Organisms may enter the circulatory system via the intravenous insertion site, directly
from the catheter, from the giving of IV fluids, or from another site in the body via
the bloodstream.2–7 Because the RCP’s help is becoming more necessary in transport
and resuscitation teams and in bronchoscopy suites, it is essential for the RCP to be
proficient in obtaining intravenous access and assisting with the maintenance of the
catheters.
OBJECTIVES 1. Demonstrate proper patient identification procedures.

Upon completion of this 2. Practice the communication skills required for assessing the level of patient comprehension of
chapter, you will be able to: the procedure.
4. Demonstrate the proper selection and use of the equipment necessary for insertion and
maintenance of an intravenous catheter.
5. List the preferred venous access sites, and identify factors to consider in site selection.
6. Demonstrate the ability to differentiate between the feel of a vein, tendon, and artery.
7. Demonstrate the adequate preparation of a patient.
8. Demonstrate the adequate preparation of the venous access site.
9. Demonstrate the proper connection of the intravenous fluids to the catheter.
10. Demonstrate the adequate maintenance of the insertion site.
11. Demonstrate the removal of the intravenous catheter.
12. Demonstrate the application of proper safety and infection control measures.
KEY TERMS
angiocath dressing intravenous solution
biohazard containers intravenous catheter intravenous tubing
589
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Exercises
F Absorbent pad or towel F Intravenous fluids
F Alcohol prep pads F IV tubing and IV poles
F Artificial phlebotomy practice arms and blocks F Personal protective equipment: gloves,
F Biohazard waste containers goggles, safety shields, lab coats, masks
F Dry, sterile sponges F Phlebotomy chairs with locking armrests
F Gauze sponges F Povidone-iodine wipes/swabs
F Holder/adapter F Securing devices/tape
F Infusion pump F Semitransparent occlusive dressings
F Intravenous catheters or angiocaths of F Sharps container
different gauges F Tourniquet
EXERCISE 34.1 IDENTIFICATION OF VEINS AND CATHETER PARTS
Review the procedure in Use the following list to identify the parts of an intravenous catheter that are indicated in
Exercise 33.1 to identify Figure 34.1 and record the parts in your lab report.
veins. Avoid hand veins Teflon angiocatheter
because of the risk of Needle
nerve injuries. Connection for IV tubing
Hub
C D
B
Figure 34.1. Components of A
an IV catheter.
EXERCISE 34.2 PREPARATION OF THE SUBJECT FOR INTRAVENOUS INSERTION
Scenario: Valentina Forgy is a 23-year-old Caucasian woman admitted to the emergency depart-
ment after a motor vehicle collision. She appeared to suffer a splenic injury and tomography
reveals fluid in the abdomen consistent with bleeding. An IV catheter needs to be inserted in the
right arm so that IV fluids can be initiated to replace her blood loss. To perform this exercise,
you will need a laboratory partner to simulate a patient and a phlebotomy training device or
venipuncture arm plus an IV fluid setup.
1. Identify the relevant patient history and record it on your laboratory report.
EXERCISE 34.3 INTRAVENOUS INSERTION PROCEDURE
1. Verify the physician’s order and identify the “patient.”

2. Wash your hands.
3. Gather the equipment. Check that you have the correct IV fluid with prescribed additives
if necessary. Examine the IV fluid for sterility and ensure that there is no discoloration or
particles of crystallization in the fluid. Verify the expiration dates on the IV fluids.
4. Prepare the IV infusion and prime tubing.
5. Introduce yourself and explain the procedure.
6. Don clean gloves.
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C H A P T E R 34 | I N T R AV E N O U S I N S E R T I O N AND M AINTENANC E • 591
7. Approach the “patient” in a friendly, calm manner. Provide for the “patient’s” comfort as
much as possible and gain the “patient’s” cooperation.
8. Position the “patient.” Hyperextend the “patient’s” arm.
9. Place the “patient’s” arm in a straight and independent position, if possible.
10. Select the appropriate venipuncture site. Avoid shaving but trim hair with scissors or
clippers.
11. Palpate and trace the path of the “patient’s” veins with the index finger. Arteries pulsate,
are most elastic, and have thick walls.
12. Place an absorbent pad or towel under the arm to prevent soiling the linen with blood.
13. Place the equipment close to the work area.
14. Apply a tourniquet 3 to 4 inches above the selected puncture site.
15. Clean the insertion site with an antiseptic solution starting at the insertion site and moving
in a circular fashion about 2 inches away from the site.
16. Allow the site to air dry. Do not palpate the site after applying antiseptics if wearing
nonsterile gloves.
17. Select the smallest-gauge catheter possible. For routine hydration, a 22- to 27-gauge
catheter is appropriate.
18. Inspect the catheter before insertion to ensure that the needle is fully inserted into the
plastic cannula. Prior to venipuncture, hold the catheter hub and rotate the barrel 360° to
loosen the connection.
19. Hold the “patient’s” skin taut with your nondominant hand. Perform the venous insertion
with the bevel of the needle inside the catheter pointed up at a 15° to 30° angle.
20. Thread the catheter along the path of the vein. Observe for flashback along the catheter.
21. Upon flashback, lower the catheter almost parallel to the skin.
22. Advance the entire unit slightly before threading the catheter.
23. Thread the catheter into the vein while maintaining skin traction.
24. Release the tourniquet.
25. Apply digital pressure beyond the catheter tip.
26. Gently stabilize the catheter hub.
27. Remove the needle.
28. Flush the cannula with normal saline.
29. Connect the primed IV administration to the catheter hub. Handle sterile connections with
sterile gloves. Use sterile scissors to anchor the catheter.
30. Initiate the flow of IV fluid and assess for signs of extravasation or infiltration.
31. Secure the catheter with tape.
32. Cover with transparent, semipermeable polyurethane dressings where possible to allow
visual inspection of the insertion site. Use sterile gauze dressings if the “patient” is
perspiring profusely or if the insertion site is bleeding or oozing (Fig. 34.2).
33. Set the fluid infusion rate manually or by using an IV pump (Fig. 34.3).
34. Label dressing with the date, time, catheter gauge, and initials (Fig. 34.4).
35. Reconfirm the flow after securing the IV catheter.
36. Discard the supplies in a biohazard container.
NOTE: Do not bend, break, recap, or resheath needles to avoid accidental needle puncture or
splashing of contents.
37. Summarize the steps of the procedure and record the steps on your laboratory report.
39. Record the type of solution, the amount, and the rate of flow on your laboratory report.
Figure 34.2. IV site dressing.
2679_Ch34_589-600.indd 591 07/02/13 4:47 PM

Figure 34.3. IV pump.
08
7:3 /31/16
0S
EG
Figure 34.4. Labeling of an IV dressing.
EXERCISE 34.4 INTRAVENOUS RATE INFUSION CALCULATION
The goal of this exercise is for you to be able to calculate the infusion rate to ensure that the
patient receives the correct volume of fluid.
First, calculate the hourly rate: You must calculate the hourly rate if it is not specified in the
physician’s order.
Volume to be infused
= Infusion rate
Number of hours it is to be infused
Next, calculate the drip rate: This is done by using the following calculation. The drip factor is
the number of drops necessary to deliver 1 mL of solution. IV tubing has a drip factor that is set
by the manufacturer.
(Hourly rate in mL) × (No. of drops/mL [drip factor])
= drops/minute (drip rate)
60 minutes
EXERCISE 3 4 .4 .1 S C EN AR IO 1
Dr. Cohen has ordered your patient to receive 125 mL of D5W an hour for the next 24 hours.
The patient care unit uses tubing with a drip factor of 10. What is the drip rate? Calculate and
record your answer in the laboratory report.
Dr. Usuga has ordered 1 L of D5W to run this 8-hour shift. If the drip factor is 15, what will be the
rate of infusion in drops per minute? Calculate and record your answer in the laboratory report.
2679_Ch34_589-600.indd 592 07/02/13 4:47 PM

EXERCISE 34.5 INTRAVENOUS CATHETER MAINTENANCE
1. Check the insertion site at least daily and check that the line is patent before each use.
2. Remove the peripheral catheter, and resite if necessary, at least every 72 to 96 hours. If
infusing blood, blood products, or lipid emulsions, repeat this step every 24 hours.
3. Change the dressing when soiled or if no longer intact.
4. Assess the external length of the catheter to determine whether migration of the catheter has
occurred.
5. For intermittent use, use a saline flush once each week or after each use.
6. If the lumen will not flush or aspirate because it is occluded with blood, a declotting
procedure may be necessary per institution protocol.
7. Chart insertion, manipulations, and initial insertion site care on your laboratory report.
EXERCISE 34.6 INTRAVENOUS CATHETER REMOVAL
1. Remove the dressing.

2. Grasp the catheter near the insertion site.
3. Remove it slowly without using excessive force.
4. If you feel resistance, stop the removal. Apply a warm compress and wait 20 to 30 minutes.
5. Resume the removal procedure until the catheter is completely out of the insertion site.
6. Gently apply pressure until the bleeding, if any, has stopped.
7. Apply a Band-Aid® over the insertion site and follow up few minutes later to confirm that no
bleeding or oozing is present.
8. “Chart” the IV catheter removal on your laboratory report.
R E FE R E N C E S
1. Hess, DR, et al: Respiratory Care: Principles and Practice, ed. 2. Jones & Bartlett Learning, Sudbury, 2012, pp. 1197–1198.
2. O’Grady, NO, et al.: Guidelines for the prevention of intravascular catheter-related infections. MMWR 51(RR10):1–26, 2003.
3. Maki, DG, and Ringer, M: Risk factors for infusion-related phlebitis with small peripheral venous catheters: A randomized controlled trial.
Ann Intern Med 114:845–854, 1991.
4. Rosenthal, K: Tailor your IV insertion techniques for special populations. Nursing 35(5):36–41, 2005.
5. Hadaway, L: Anatomy and physiology related to IV therapy. Intravenous Therapy: Clinical Principles and Practice. WB Saunders,
Philadelphia, 1995, pp. 81–110.
6. Royal College of Nursing: Competencies: An education and training competency framework for administering medicines intravenously
to children and young people. RCN, London, Publication Code 003 005, 2005.
7. Scales, K: Vascular access: A guide to peripheral venous cannulation. Nursing Standard 19(49):48–52, 2005.
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Laboratory Report
CHAPTER 34: INTRAVEN OUS INSERTION AND MAINTENANCE
Name: Date:
Data Collection
EXERCISE 34.1 Identification of Veins and Catheter Parts
Please refer to Exercise 33.1 to identify the veins.
Label all parts of the catheter in Figure 34.1
A. _________________________________________________________________________________________
B. _________________________________________________________________________________________
C. _________________________________________________________________________________________
D. _________________________________________________________________________________________
EXERCISE 34.2 Preparation of the Subject for Intravenous Insertion
Document relevant patient history and explain its affect on the procedure: _________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
EXERCISE 34.3 Intravenous Insertion Procedure
Summarize in chronological order the most important steps to insert an intravenous catheter: __________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
2679_Ch34_589-600.indd 595 07/02/13 4:47 PM

_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Type of solution: ____________________ Amount: ________________________ Rate of flow: _________________________
EXERCISE 34.4 Intravenous Rate Infusion Calculation
Calculate the rate of infusion for Scenarios 1 and 2. Show your work.
Scenario 1 =
Scenario 2 =
EXERCISE 34.5 Intravenous Catheter Maintenance
“Chart” the maintenance of an intravenous catheter: __________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
EXERCISE 34.6 Intravenous Catheter Removal
“Chart” the removal of an intravenous catheter: ______________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________

1. What is the corrective action if resistance is felt while removing the catheter?
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2. If routine hydration is ordered, what type of catheter should you use?
3. What is the purpose of using transparent dressings?
4. Upon checking a patient’s IV therapy, you discover that the IV fluid has been running too slowly for the past hour.
Should you adjust the rate at a higher infusion rate to make up for the loss of administration?
5. What should be done if you find that the IV fluid has been running too fast for the past hour?
6. When preparing for the insertion of an IV catheter in an older adult, why should the RCP take precaution in scrubbing
the skin gently?
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2679_Ch34_589-600.indd 598 07/02/13 4:47 PM

STUDENT: DATE:
IV INSERTION
PERFORMANCE LEVEL
PERFORMANCE RATING
Performance Level:
NA = Not applicable
Performance Rating:


3. Selects the proper IV fluid per MD order
4. Assembles the IV administration set and primes the tubing
5. Selects the proper gauge IV catheter
6. Selects a suitable site for IV insertion by palpating and tracing the patient’s veins
7. Applies the tourniquet 3–4 in. above puncture site
8. Tightens the tourniquet and asks the patient to make a fist
9. Cleanses the puncture site with an antimicrobial swab in a circular fashion moving 2 inches away from the puncture site
10. Holds the patient’s skin taut with the nondominant hand
11. Inserts the needle at a 15° to 30° angle with the bevel up
12. Threads the needle into the patient’s vein and observes for a backflow of blood into the needle or syringe
13. Loosens the tourniquet
14. Removes the needle while holding the catheter stable
15. Connects the primed IV tubing
16. Initiates the flow of the IV fluid
17. Assesses for infiltration or extravasation
18. Secures the catheter with tape
19. Covers the site with a transparent, semipermeable dressing, allowing for visualization of the puncture site
20. Labels the dressing with the date, time, catheter size, and initials
21. Initiates the fluid infusion rate manually or by IV pump per MD order
22. Reconfirms the flow of the IV fluid
23. Discards all used supplies in a biohazard container
FOLLOW-UP
2679_Ch34_589-600.indd 599 07/02/13 4:47 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
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CHAPTER Chest Tube
Drainage Systems
INTRODUCTION Excess air or fluid may accumulate in the pleural space due to pneumothorax, pleural
effusion, hemothorax, chylothorax, empyema, or following thoracic surgery. As a result,
the negative pressure normally found in the pleural cavity is disrupted and the patient
will develop shortness of breath and an increase in work of breathing. Over time, the
body can absorb small volumes of air and/or fluid, but lung expansion will be limited by
large volumes.1–6
The purpose of the chest tube is to remove air and/or fluid from the pleural cavity to help
reestablish normal intrathoracic pressures. This aids in the reexpansion of the lung and
restoration of normal breathing dynamics. Once the chest tube is in place, it is connected
to a chest drainage system. The purpose of the chest drainage system is to collect fluid
as it drains from the pleural cavity, allow air to exit the pleural cavity, and provide suction
for enhanced pleural drainage.1–6
OBJECTIVES 1. Identify the parts of a chest drainage system.

Upon completion of this 2. Discuss the function of each of the three chambers of a chest drainage system.
3. Demonstrate the proper setup of a chest drainage system.
4. Compare and contrast a water-seal system to a dry suction chest drainage system.
5. Discuss the maintenance and troubleshooting of the chest drainage system.
KEY TERMS
chylothorax pleural space water-seal chamber
collection chamber suction control chamber
hemothorax tidaling
601
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Exercises
F Chest tube F Sterile water
F Dry chest drainage system F Suction source
F Human patient simulator (if available) F Suction tubing
F Nonsterile disposable nonlatex gloves, F Wet chest drainage system
various sizes
EXERCISE 35.1 WET CHEST DRAINAGE SYSTEMS

EXERCISE 35.1.1 WET C HES T DR AIN A G E S Y S T E M C O MP O N E N T I D E N T I FI C AT I O N
Compare the equipment provided in the laboratory with Figure 35.1. Identify each item and
Calibrated water-seal chamber High-negativity relief valve
Carrying handle Patient air leak meter
Collection chamber Positive-pressure relief valve
High-negativity float valve and relief chamber Self-sealing diaphragm
Suction control chamber
Figure 35.1. Pleur-evac® wet chest drainage system.
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C H A P T E R 35 | C H E S T T U B E DR AINAGE S Y S TEM S • 603
EXER C ISE 35 .1 .2 ASSEMB LI N G A W E T C H E S T T U B E D R A I N A G E S Y S T E M

3. Remove the chest drainage system from its packaging. Record the brand used on your
laboratory report.
4. Lock the floor stand into place.
5. Instill sterile water into the water-seal chamber.
A. Attach a funnel to the short suction chamber tubing.
B. Kink the tubing by holding the funnel below the top of the chest drainage unit.
C. Fill the funnel with sterile water to the 2 cm level.
D. Raise the funnel above the chest drainage unit to fill the water-seal chamber.
6. Connect the “patient’s” chest tube to the collection chamber tube.
7. Pour sterile water directly into the suction control chamber through the atmospheric vent to
the prescribed level (usually 20 cm).
8. Connect the suction tubing to the suction source if suction is required.
A. Gradually increase the wall suction until gentle bubbling is seen in the suction control
chamber.
9. Position the chest drainage system so that it is hanging from the bed or standing on the
floor. The unit should be at least 1 foot below the level of the “patient’s” chest.
10. Assess the “patient” for signs of respiratory distress.
11. Assess the chest tube entry site for drainage and subcutaneous emphysema.
12. Assess all the tubing and ensure that there are no kinks or dependent loops and all
connections are tightly connected.
13. Assess the chest drainage unit:
A. Assess the suction control chamber:
i. Ensure that the suction level in the suction control chamber is set at the ordered
level.
ii. Assess the suction control chamber for gentle, continuous bubbling.
iii. If the “patient” is not on suction, ensure that the air vent is open.
B. Assess the water-seal chamber:
i. Ensure that the water-seal chamber is filled to the appropriate level.
ii. Assess the water-seal chamber for bubbling and tidaling.
C. Assess the collection chamber:
i. Assess the volume, type, and rate of drainage.
EXERCISE 35.2 DRY CHEST DRAINAGE SYSTEMS

EXER C ISE 35 .2 .1 DRY C H E S T D R A I N A G E S Y S T E M C O MP O N E N T I D E N T I FIC AT I O N
Compare the equipment provided in the laboratory with Figure 35.2. Identify each item and
Calibrated water seal Patient air leak meter
Carrying handle Positive-pressure relief valve
Collection chamber Self-sealing diaphragm
High-negativity float valve and relief chamber Suction control dial
High-negativity relief valve Suction control indicator window
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Figure 35.2. Pleur-evac® dry chest drainage system.
EXERCISE 3 5 .2 .2 ASSEMBLIN G A DRY C H E S T T U B E D R A I N A G E S Y S T E M

3. Remove the chest drainage system from its packaging. Record the brand used on your
laboratory report.
4. Lock the floor stand into place.
5. Connect the “patient’s” chest tube to the collection chamber tube.
6. Add sterile water to the water-seal chamber through the needleless injection site on the back
of the unit if applicable.
7. Connect the suction tubing to the suction source if suction is required.
A. Set the dry suction control dial to the desired suction setting.
B. Gradually increase wall suction until the desired suction level appears in the suction
control indicator.
8. Position the chest drainage system so that it is hanging from the bed or standing on the
floor. The unit should be at least 1 foot below the level of the “patient’s” chest.
9. Assess the “patient” for signs of respiratory distress.
10. Assess the chest tube entry site for drainage and subcutaneous emphysema.
11. Assess all the tubing and ensure that there are no kinks or dependent loops and all
connections are tightly connected.
12. Assess the chest drainage unit:
A. Assess the suction control chamber:
i. Ensure that the suction level in the suction control indicator is set at the ordered
level.
ii. Ensure that the suction source indicator is visible.
iii. If the “patient” is not on suction, ensure that the air vent is open.
B. Assess the water-seal chamber:
i. Ensure that the water-seal chamber is filled to the appropriate level.
ii. Assess the water-seal chamber for bubbling and tidaling.
C. Assess the collection chamber:
i. Assess the volume, type, and rate of drainage.
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EXERCISE 35.3 MAINTAINING AND TROUBLESHOOTING CHEST DRAINAGE SYSTEMS
Using outside sources, complete Table 35.1 and record your answers on your laboratory report.
Table 35.1 Maintaining and

Location Assessment Indication/ Action
Troubleshooting Chest Drainage
Systems Collection Chamber Drainage has suddenly stopped.
The collection chamber is full.
Water-Seal Chamber The water level is not at 2 cm. -proper operation not ensured
This is a normal finding called tidaling.
Tidaling is not seen. -chest tube is not patent
Continuous bubbling is seen.
This indicates that the patient has an
air leak in the pleural space. This is
expected during expiration in a patient
with a pneumothorax. Notify the
physician if this is a new leak.
This indicates that the lung has reexpanded
and air is no longer leaking into the
pleural space. Verify full lung expansion
on the chest x-ray.
Wet Suction Control There is too much water in this chamber.
Aggressive bubbling is seen. too much fluid in chamber
Continuous gentle bubbling is seen. enough fluid
No bubbling is seen. -not enough fluid
Dry Suction Control The suction control indicator is not visible. -cant adjust amt of suction and
respond to air leaks
R E FE R E N C E S
1. Carroll, P: Exploring chest drain options. RN 63(10):50–58, 2000.
2. Coughlin, A, and Parchinsky, C: Go with the flow of chest tube therapy. Nursing 36(3):36–41, 2006.
3. Erickson, R: Mastering the ins and outs of chest drainage. Part 2. Nursing 19(6):46–49, 1989.
4. O’Hanlon-Nichols, T: Commonly asked questions about chest tubes. Am J Nursing 96(5):60–64, 1996.
5. Roman, M, and Mercado, D: Review of chest tube use. Nursing 15(1):41–43, 2006.
6. Rushing, J: Clinical do’s & don’ts: Managing a water-seal chest drainage unit. Nursing 37(12):12, 2007.
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Laboratory Report
CHAPTER 35: CHEST TUBE DRAINAGE SYSTEMS
Name: Date:
Data Collection
EXERCISE 35.1 Wet Chest Drainage Systems
E X E R C IS E 35 . 1. 1 W E T C H E S T DRAIN AGE SYSTEM COMPON EN T IDEN TIF ICATION
A. ____________________________________________________________________________________
B. ____________________________________________________________________________________
C. ____________________________________________________________________________________
D. ____________________________________________________________________________________
E. ____________________________________________________________________________________
F. ____________________________________________________________________________________
G. ____________________________________________________________________________________
H. ____________________________________________________________________________________
I. ____________________________________________________________________________________
E X E R C IS E 35 . 1. 2 A S S E M B LIN G A W ET CHEST TUBE DRAIN AGE SYSTEM
Brand used: _____________________________________________________________________________
EXERCISE 35.2. Dry Chest Drainage Systems
E X E R C IS E 35 . 2. 1 D R Y C H E S T DRAIN AGE SYSTEM COMPON EN T IDEN TIF ICATION
A. ____________________________________________________________________________________
B. ____________________________________________________________________________________
C. ____________________________________________________________________________________
D. ____________________________________________________________________________________
E. ____________________________________________________________________________________
F. ____________________________________________________________________________________
G. ____________________________________________________________________________________
H. ____________________________________________________________________________________
I. ____________________________________________________________________________________
J. ____________________________________________________________________________________
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E XE RCI SE 3 5 .2 . 2 A S S E M B LIN G A D R Y C H E S T TUBE DRAIN AGE SYSTEM
Brand used: _____________________________________________________________________________
EXERCISE 35.3 Maintaining and Troubleshooting Chest Drainage Systems
Table 35.1 Maintaining and

Location Assessment Indication/ Action
Troubleshooting Chest Drainage
Systems Collection Chamber Drainage has suddenly stopped. -tubing occlusion, or suction is off
The collection chamber is full. -dispose n need new drainage system
Water-Seal Chamber The water level is not at 2 cm. -add more water or remove excess
water seal moves up n down This is a normal finding called tidaling.
Tidaling is not seen. -chest tube occlusion, too much suction, all air is
out of the lung n pt is better
Continuous bubbling is seen.
This indicates that the patient has an
continuous bubbling=-air leak, too much peep air leak in the pleural space. This is
expected during expiration in a patient
-intermittent bubbling with a pneumothorax. Notify the
physician if this is a new leak.
This indicates that the lung has reexpanded
-No bubbling and air is no longer leaking into the
pleural space. Verify full lung expansion
on the chest x-ray.
Wet Suction Control There is too much water in this chamber. -remove excess water
Aggressive bubbling is seen. water evaporated less suction observed
Continuous gentle bubbling is seen. good
No bubbling is seen. -occlusion, suction off
Dry Suction Control The suction control indicator is not visible. no suction

1. Describe the function of the three chambers of a chest drainage unit.
collection chamber: collect drainage from pleural cavity

Water seal chamber: allow air to exit pleural cavity during exhalation thru a one way valve
monitor intrathoracic pressure
wet/dry suction chamber: for suctioning
2. Your patient has a chest tube in place and is showing signs of respiratory distress. What is the most likely cause of
these findings and what would you do at this time?
-can cause or worsen pneumothorax
3. If your patient with a chest tube develops swelling of chest tissue and you hear a crackling sound upon palpation of the
area, what would you suspect?
swelling and crackling- subcutaneous emphysema

air trapped in area
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4. Describe tidaling in the following patients:
A. Spontaneously breathing
water float will rise with inspiration and falls with expiration
B. Mechanically ventilated
water float will drop with inspiration and rise with exhalation
5. State three conditions that are indicated by the absence of tidaling in the water-seal chamber and how to troubleshoot
each situation, if necessary.
kink in tube, placement of tube, absence of tidaling is patient is getting better
6. You are caring for a patient with a treated pneumothorax receiving mechanical ventilation with positive end-expiratory
pressure. What type of bubbling in the water-seal chamber would you expect to see?
-continuous bubbling
-leak may increase with increase from spontaneous ventilation and with increase in pressure used to
inflate the lungs
7. While auscultating a patient with a chest tube, you note a sucking sound near the entrance of the chest tube. What is
the most likely cause of this finding and what would you recommend be done at this time?
incision could be too large and not sealed and air is being
pulled into the lungs,
- need to reseal the incison
8. When should a chest tube be removed?
-when all the fluid/ air hasbeen drained from the pleural cavity
-when the bubbling has topped
-pt is breathing normally without respiratory distress
9. A patient suffering from lung cancer is admitted to the hospital with a large pleural effusion that has been increasing in
size due to the progression of the cancer. The physician recommends that the patient be admitted to the hospital and a
chest tube drainage system be placed. The physician orders a chest tube drainage system without suction. Explain why
suction is not recommended for this patient.
Since they had a pleural effusion for a long time the lung gets used to being compressed and this
changes their pulmonary vascular resistance, if you open it up very rapidly(remove the effusion), it
increases the hydrostatic pressure in the lungs as blood pushes very fast and can cause
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10. A patient admitted to the hospital has been diagnosed with a pneumothorax. A chest tube drainage system is placed
and the position of the chest tube is verified and documented by chest x-ray. While examining the patient, you note
that the most proximal hole of the chest tube is outside of the patient’s skin. How would this affect the chest drainage
system?
chest tube is out of chest wall
-the drainage will reduce

-tape the incision closed, inform physician
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STUDENT: DATE:
CHEST DRAINAGE SYSTEM ASSEMBLY
PERFORMANCE LEVEL
PERFORMANCE RATING
Performance Level:
NA = Not applicable
Performance Rating:

2. Locks the floor stand into place
3. Instills sterile water into the water-seal chamber
4. Connects the patient’s chest tube to the collection chamber tube
5. Instills sterile water into the suction control chamber to the prescribed level (wet system)
6. Connects the suction tubing to the suction source if required
7. Sets the dry suction control dial to the desired suction setting (dry system)
8. Adjusts the vacuum pressure to the appropriate level
9. Positions the chest drainage system appropriately

11. Assesses the chest tube entry site
12. Assesses all tubing
13. Assesses the suction control chamber
14. Assesses the water-seal chamber
15. Assesses the collection chamber
FOLLOW-UP
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PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
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CHAPTER Bronchoscopy
Assisting
INTRODUCTION Bronchoscopy is the general term used to describe the insertion of a visualization
instrument (endoscope) into the bronchi. It has become an increasingly important
diagnostic and therapeutic tool for the management of patients with pulmonary disease.
Although this chapter will emphasize flexible bronchoscopy, respiratory care practitioners
(RCPs) should gain some basic knowledge of rigid bronchoscopy.
The rigid bronchoscope is an open metal tube with a distal light source and a port for
attaching oxygen or ventilating equipment. Otorhinolaryngologists or thoracic surgeons
use the rigid bronchoscope the most. It requires general anesthesia and, therefore, the use
of an operating suite and the services of an anesthesiologist. Rigid bronchoscopy cannot
access the smaller airways. Some of the indications for rigid bronchoscopy include
massive hemoptysis, laser therapy, foreign body retrieval, and placement of airway stents.
Flexible bronchoscopy has progressively replaced rigid bronchoscopy. The main

indications for performing a flexible bronchoscopy are inspection of the airway, removal
of objects from the airway, collection of samples from the airway, and the placement of
devices into the airway.1 Additionally, in the intensive care setting bronchoscopy may be
used in the placement or change of an endotracheal tube, evaluation of chemical/thermal
injuries, and evaluation of the upper airway after extubation.
RCPs can help prepare all the required equipment and assist the physician with the
procedure.2,3
OBJECTIVES 1. Practice communication skills required for assessing the level of patient comprehension of the
Upon completion of this procedure.
chapter, you will be able to: 2. Practice medical charting for the bronchoscopy procedure.
4. Identify the indications for rigid and flexible bronchoscopy.
5. Select the proper equipment necessary to assist during a bronchoscopy.
6. Assemble and verify equipment function.
7. Demonstrate the use of the different ports of the bronchoscope.
8. Demonstrate the adequate preparation of patient.
9. Demonstrate the adequate preparation of the airway.
10. Demonstrate the setup of monitoring devices required during bronchoscopy.
11. Relate the complications that may be encountered during the insertion and manipulation of a
bronchoscope.
12. Discuss the criteria for discharging the patient from the bronchoscopy suite.
613
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KEY TERMS
bite block flexible bronchoscopy rigid bronchoscopy
bronchoscope hemoptysis thumb control
Exercises
F 5-, 10- and 20-mL syringes, Luer-Lok™ F Jackson forceps
F 5-, 10- and 20-mL syringes, non–Luer-Lok™ F Laboratory specimen forms
F Adhesive tape F Masks
F Alcohol wipes F Medicine cups
F Atomizer and accessories F Needles, blunt tip
F Band-Aids® F Needles, sharp tip
F Bite block F Nonbacteriostatic saline
F Bronchoscope accessories F Oxygen cannula
F Bronchoscope light source F Physician order forms
F Bronchoscopy charge slips F Pulse oximeter
F Cardiac monitor F Radiology requisitions
F Consent forms F Saline
F Cotton 4×4 and 2×2 pads F Sedatives (e.g., meperidine, codeine, mor-
F Cotton balls phine, diazepam, midazolam)
F Denture cups F Specimen cups
F ECG leads F Specimen labels
F Emesis basins F Specimen slides
F Endotracheal tubes F Sputum traps
F Epinephrine 1:1000 F Sterile swabs
F Fiberoptic bronchoscope adapter F Suction pump
F Gloves F Suction tubing
F Gown F Topical anesthetics (e.g., lidocaine [1%, 2%,
F Heparin lock flush solution and 4%], cocaine [4% or 10%], Cetacaine)
F Heparin locks or caps F Yankauer-type suction catheters
F Intravenous catheters or “butterflies” F Water-soluble lubricant
EXERCISE 36.1 IDENTIFICATION OF COMPONENTS
Identify the components of a typical fiberoptic bronchoscope, as shown in Figure 36.1, and
record them on your laboratory report:
Connection to the light and video source
Brush/forceps/instillation port
Suction/oxygen port
Camera attachment/eyepiece
Thumb control
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C H A P T E R 36 | B R O N C HOS C OP Y AS S IS TING • 615
D
C
A-light source connection
B-channel port B
C-processor connection
D-eyepiece
E-control section
E
Figure 36.1. Components of a flexible fiberoptic

bronchoscope.
EXERCISE 36.2 PREPARATION OF THE PATIENT FOR BRONCHOSCOPY
To perform this exercise, you Scenario: Paula Swanson is a 43-year-old Hispanic woman with a history of hemoptysis. A chest
will need a mannequin and a radiograph showed a mass in the right middle lobe. She has been scheduled for a bronchoscopy
laboratory partner to and possibly a biopsy.
simulate a clinical situation. Before the initiation of the bronchoscopic procedure:
1. Ask the patient whether she has ingested food or drink in the last 8 hours.
2. Explain the need for premedication with benzodiazepines prior to the procedure to decrease
anxiety.
3. Obtain vascular access.
4. Record the relevant patient history on your laboratory report.
EXERCISE 36.3 EQUIPMENT PREPARATION FOR BRONCHOSCOPY
1. Check the orders to confirm the request for bronchoscopy, patient information including
laboratory diagnostics (prothrombin time, partial thromboplastin time, bleeding times, and
platelet counts), and any special requirements or physician’s orders prior to the procedure.
2. Wash your hands.
3. Gather the equipment and check for proper function, tight connections, and integrity of the
following.
A. Light
B. Thumb control
C. Eyepiece focus
D. Patency of suction and biopsy channel
4. Record verification of proper function on your laboratory report.
2679_Ch36_613-624.indd 615 07/02/13 4:47 PM

EXERCISE 36.4 BRONCHOSCOPY PROCEDURE
For this exercise, you will 1. Identify the “patient.”

need a laboratory partner 2. Introduce yourself and explain the procedure.
and a mannequin to simulate 3. Approach the “patient” in a friendly, calm manner. Provide for the “patient’s” comfort as
a patient undergoing much as possible, and gain the “patient’s” cooperation. Create a calm and soothing
bronchoscopy. environment.
4. Don a clean gown, mask, goggles, and gloves.
5. Organize the equipment close to the work area. Label and fill four medication cups with the
following medications to be placed on the work surface for quick access:
F Cup one: 3 mL 4% topical Xylocaine (to be used if needed above the vocal cords)
F Cup two: 6 mL 2% topical Xylocaine (to be used if needed below the vocal cords)
F Cup three: 15 mL 0.9% sodium chloride (NaCl) for irrigation
F Cup four: 1:19 solution of epinephrine (1 mL 1:1,000 epinephrine diluted with 19 mL
0.9% NaCl)
6. Place a labeled syringe next to each labeled medication cup. Provide two 5-mL syringes for
use with Xylocaine and two 10-mL syringes for use with NaCl and epinephrine on the
work surface.
7. Set up the suction equipment with a sterile 80-mL specimen trap placed in-line between the
suction source and the bronchoscope. Ensure the proper function of suction. Provide several
specimen traps for the procedure.
8. Place four sets of frosted slides back to back labeled with the patient’s name, identification
number, physician’s name, and date of procedure.
9. Place the “patient” in a Fowler’s position. Prepare the airway on the mannequin:
A. Apply topical vasoconstrictors to prevent bleeding through nasal passage if indicated
by the physician.
B. Administer a medicated nebulizer treatment containing 5 mL of 4% topical Xylocaine
over a 20-minute period.
C. Insert the IV line with the heparin lock. Flush with heparin and secure into place.
10. Set up monitoring devices on your laboratory partner:
A. Connect pulse oximetry. Provide supplemental oxygen via nasal cannula if necessary.
B. Attach the leads to the continuous electrocardiogram monitor.
C. Place the blood pressure cuff around the “patient’s” arm. Record the patient
assessment data on your laboratory report.
11. During mechanical ventilation (you need an intubated mannequin for this exercise):
A. Increase Fio2 to 1.0.
B. Maintain PEEP at preset levels.
C. Attach a fiberoptic bronchoscope adapter, as shown in Figure 36.2, to the endotracheal
tube adapter to introduce the bronchoscope.
D. Adjust the high-pressure alarm on the ventilator if necessary. Record the adjustments
made to the ventilator on your laboratory report.
12. Insert a bite block.
13. Insert the bronchoscope (physician).
14. Introduce forceps and brushes.
15. Introduce syringes filled with anesthetic, vasoconstrictor, mucolytic agents, or lavage
solution as available in your lab.
16. Apply suction to simulate sputum or tissue sampling.
17. Remove the bronchoscope.
18. Clean bronchoscope using a glutaraldehyde disinfecting solution.
Figure 36.2. Fiber-optic bronchoscope adapter. (Courtesy

of Smiths Group PLC, Rockland, MA.)
2679_Ch36_613-624.indd 616 07/02/13 4:47 PM

C H A P T E R 36 | B R O N C H OS C OP Y AS S IS TING • 617
EXERCISE 36.5 BRONCHOSCOPY RECOVERY
To perform this exercise, you Before discharge you will:

will need a partner to 1. Confirm the “patient’s” blood pressure, heart rate, and respiratory rate.
simulate a patient after the 2. Confirm adequate oxygenation by measuring pulse oximetry on your “patient.”
bronchoscopic procedure. 3. Keep the “patient” in a sitting position until fully awake and alert.
4. Instruct the “patient” to refrain from eating or drinking until sensation is fully recovered.
5. Assess for the presence of stridor and/or bronchospasm.
6. “Chart” the postbronchoscopy assessment on your laboratory report.
EXERCISE 36.6 BRONCHOSCOPY COMPLICATIONS
Using your textbooks and other sources, prepare a list of common complications associated with
bronchoscopy. List them in increasing order of severity. Record the list on your laboratory report.
R E FE R E N C E S
1. Leibler, JM, and Markin, CJ: Fiberoptic bronchoscopy for diagnosis and treatment. Crit Care Clin 16:83, 2000.
3. Treanor, S, Benitez, WD, and Raffin, TA: Respiratory therapists as fiberoptic bronchoscopy assistants. Respir Care 30(38):321, 1985.
2679_Ch36_613-624.indd 617 07/02/13 4:47 PM

2679_Ch36_613-624.indd 618 07/02/13 4:47 PM
Laboratory Report
CHAPTER 36: BRONCHOSCOPY ASSISTING
Name: Date:
Data Collection
EXERCISE 36.1 Identification of Components
Label all of the parts of the bronchoscope in Figure 36.1:
A. ____________________________________________________
B. ____________________________________________________
C. ____________________________________________________
D. ____________________________________________________
E. ____________________________________________________
EXERCISE 36.2 Preparation of the Subject for Bronchoscopy
Scenario: Relevant patient history and its impact on the procedure:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
EXERCISE 36.3 Equipment Preparation for Bronchoscopy
Verification of equipment function:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
EXERCISE 36.4 Bronchoscopy Procedure
Patient assessment data:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Adjustments made to the mechanical ventilator:
____________________________________________________________________________________________________________
2679_Ch36_613-624.indd 619 07/02/13 4:47 PM

EXERCISE 36.5 Bronchoscopy Recovery
Postbronchoscopy assessment:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
EXERCISE 36.6 Bronchoscopy Complications
Name four common complications during bronchoscopy:
1. _____________________________________________________
2. _____________________________________________________
3. _____________________________________________________
4. _____________________________________________________

1. For Ms. Swanson in Exercise 36.2, would you have recommended rigid bronchoscopy? YES ____ NO _____. Explain
your answer.
No
Bc in a rigid bronchoscopy you wouldn't be able to go all the way down to get the sample from the mass in the right
middle lobe
2. While a bronchoscopy is being performed on a mechanically ventilated patient, you notice that the high-pressure alarm
is sounding. What are the possible causes and corrective actions?
-caused by an increase in res pressure in the patient

-so u can increase the high pressure alarm limit
3. If the physician informs you that the light on the scope is no longer visible, what would you suggest to correct the
problem?
suction the pt, there might be a build up of secretions
first make sure that the scope is still attached to the light source and that the connection is tight. if the
connection is secure suggest replacing the scope
4. A pulmonary fellow is performing her first bronchoscopy and informs you that the entire airway is blurry and suggests
instillation of saline to clear the scope. You proceed with the instillation of saline and suction but the field fails to clear.
What would you suggest in order to clear the field?
Adjust the focus on the eye piece
2679_Ch36_613-624.indd 620 07/02/13 4:47 PM

5. A patient with documented hypertension has been scheduled for a flexible bronchoscopy. Which of the commonly ad-
ministered medications during bronchoscopy might cause an adverse reaction? Explain your answer in detail.
-epinephrine is used
-it is a vasoconstrictor, so it increases the bp for the hypertensive patient
6. What is the difference between diagnostic and therapeutic bronchoscopy? List three indications for each.
diagnostic- informative for the team

therapeutic- condition from an unknown problem
7. While assisting with a bronchoscopic procedure for a patient on a mechanical ventilator, you notice that the PEEP has
been steadily increasing as the physician inserts the bronchoscope through the endotracheal tube into the airways.
What may be the cause of this and what should be done?
-bronchoscope inserted thru the airway is causing a decrease in the radius so adjust parameters
to maintain PEEP
8. Mr. Levy is in the recovery room following a bronchoscopy. He is seated upright in bed with a 2 Lpm nasal cannula in
place. His vital signs are stable but oxygen saturations are beginning to fall below 88%. The patient begins to com-
plain of difficulty breathing. Upon auscultation, you can hear wheezing throughout the upper airways on inspiration
and expiration. What would you suggest be done for this patient?
-recommend bronchodilator therapy and oxygen given to the pt to improve oxygen

saturation levels
9. A patient is undergoing a bronchoscopy for removal of thick, inspissated secretions. While performing the procedure
and monitoring the patient, you note that the patient’s oxygen saturation has fallen from 95% to 84%. Though you
have increased the oxygen delivery from 3 Lpm nasal cannula to 6 Lpm nasal cannula, the oxygen saturation has not
changed. What would you suggest be done for this patient?
-stop procedure temporarily while oxygen is given to the patient down the open port of the bronchoscope.
resume after the pt has stabilized
2679_Ch36_613-624.indd 621 07/02/13 4:47 PM

2679_Ch36_613-624.indd 622 07/02/13 4:47 PM

STUDENT: DATE:
BRONCHOSCOPY ASSISTING
PERFORMANCE LEVEL
PERFORMANCE RATING
Evaluator: Setting:
Performance Level:
NA = Not applicable
Performance Rating:


3. Observes/assists with the preparation of the bronchoscope
4. Reviews the indications, contraindications, hazards, and precautions of the procedure
5. Assists with the procedure as instructed by the physician
6. Administers any anesthetic or medication as instructed
7. Communicates effectively with the patient during the procedure
8. Communicates effectively with the physician during the procedure
9. Labels any specimens according to facility policy
FOLLOW-UP
2679_Ch36_613-624.indd 623 07/02/13 4:47 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
to modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch36_613-624.indd 624 07/02/13 4:47 PM

CHAPTER Noninvasive
Ventilation
INTRODUCTION During the early to mid-1900s, polio epidemics swept across the United States. These
epidemics spurred the design of negative-pressure ventilators to provide long-term
ventilatory assistance to patients with this neuromuscular disease. Although more
physiological than positive-pressure ventilation, they proved awkward and made routine
care difficult. Today, the cuirass and the poncho ventilators provide an alternative to
positive-pressure ventilation.1
Respiratory care practitioners (RCPs) have employed other methods to positive-pressure

ventilation with varying degrees of success. Rocking beds, pneumobelts, and phrenic
nerve stimulators (diaphragmatic pacemakers) are used primarily for a select group of
quadriplegic patients in rehabilitation facilities. However, hands-on practice with these
devices is beyond the scope of the laboratory setting.2
Microprocessor-controlled positive-pressure devices are now capable of providing

another noninvasive alternative in the forms of continuous positive airway pressure
(CPAP) and bilevel positive airway pressure (BiPAP). Additionally, many critical care
ventilators now offer a noninvasive feature that allows the RCP to transition from
invasive positive-pressure ventilation to a noninvasive interface. This method of
ventilation will be discussed in more detail with mechanical ventilators. When coupled
with the appropriate mask, mouthpiece, or other interface, these devices help patients
maintain adequate ventilation in acute care and alternative locations such as long-term
facilities and home while eliminating some of the most common complications
associated with mechanical ventilation that arise from the use of artificial airways.
Besides trauma to the airway and the potential for obstruction, endotracheal tubes
and tracheostomy tubes provide a route for infection and serve as a barrier to
communication. The RCP must be familiar with the capabilities and limitations of
these devices.3 The choice of interface, ensuring proper fit, and patient comfort are
the RCP’s responsibilities and will determine the success or failure of noninvasive
ventilation for the patient.4
This lab exercise will review the equipment required for, and proper setup of,
noninvasive positive-pressure ventilation (NPPV) therapy.
625
2679_Ch37_625-638.indd 625 07/02/13 4:47 PM

OBJECTIVES 1. Practice communication skills needed for the instruction of patients or their families in
Upon completion of this noninvasive ventilator initiation.
chapter, you will be able to: 2. Identify the components of negative pressure (cuirass shell or poncho), CPAP, and
BiPAP units.
3. Assess the patient for indications requiring noninvasive ventilation.
4. Apply infection control guidelines and standards associated with noninvasive ventilation
equipment and procedures, according to OSHA regulations and CDC guidelines.
5. Select the appropriate device to deliver the prescribed negative pressure (cuirass shell or
poncho), CPAP, or BiPAP.
6. Select and properly fit the appropriate mask and headgear, mouthpiece, or other interface, as
appropriate.
7. Initiate noninvasive ventilation.
8. Troubleshoot and solve common problems associated with noninvasive ventilators.
9. Assess the patient for tolerance and response to noninvasive ventilation.
10. Titrate oxygen in conjunction with noninvasive ventilators to vary Fio2.
11. Make recommendations or modifications to ventilation techniques or equipment as needed.
12. Practice medical charting for application of noninvasive ventilation procedures.
KEY TERMS
BiPAP unit nasal mask oronasal mask
CPAP unit nasal pillows poncho
cuirass noninvasive positive-
EPAP pressure ventilation
IPAP (NPPV)
Exercises
E Q U I PM E N T R E Q U IR E D 5
F Adapters F Negative-pressure ventilators
F BiPAP unit F One-way valves
F Blood pressure cuffs and sphygmomanometer F Oxygen analyzer
F CPAP unit F Oxygen enrichment adapter
F Cuirass shells or ponchos, various sizes if F Oxygen source or concentrator
available F Oxygen supply tubing
F Head gear F Pulse oximeter
F Humidification unit F Respirometer
F Mask sizing gauge F Spacers
F Nasal masks, nasal pillows, or mouthpiece F Watch with second hand
2679_Ch37_625-638.indd 626 07/02/13 4:47 PM

C H A P T E R 37 | N O N I N VAS IV E V ENTILATION • 627
EXERCISE 37.1 NEGATIVE-PRESSURE VENTILATOR
1. Select a negative-pressure ventilator as shown in Figure 37.1. Record the type used on your
laboratory report.
2. Identify the controls. Record the available controls on your laboratory report.
3. Use your laboratory partner as the patient.
5. Identify your “patient.” Introduce yourself and your department. Explain to your partner in
nonmedical terms that you are going to place the “patient” in the noninvasive ventilator
device and what is involved. Verify that your partner understands and answer any questions
or concerns. The partner should simulate a patient’s concern and fears about having this
procedure performed. You should respond appropriately.
6. Assess the “patient” for vital signs, Spo2, breath sounds, and ventilatory status. Record
your findings on your laboratory report.
7. Prepare the “patient” for noninvasive ventilation. Select the correct size cuirass shell or
poncho.
8. Place the cuirass or poncho on the “patient” and check for proper fit and “patient”
comfort.
9. Adjust the negative pressure to –10 cm H2O.
10. Adjust the rate to 12 breaths/minute. Have your partner count from 1 to 10 as the
ventilator cycles. Record your observations on your laboratory report.
11. Using the spirometer and one-way valve, measure the exhaled tidal volume and compare it
to the desired tidal volume. Record the volume on your laboratory report.
12. Reassess your “patient’s” vital signs, Spo2, breath sounds, and ventilatory status. Record
13. Based on “patient” assessment and measured exhaled tidal volume, recommend any
appropriate settings changes to the physician.
A B
Figure 37.1. Negative pressure ventilators: (A) Poncho; (B) Cuirass.
2679_Ch37_625-638.indd 627 07/02/13 4:47 PM

14. “Chart” the application of noninvasive ventilation on your laboratory report as you would
on a legal medical record.
15. Loosen the cuirass or the poncho.
16. Measure the exhaled tidal volume and note any difference from that measured in step 11
earlier. Record the volume on your laboratory report.
EXERCISE 37.2 CONTINUOUS POSITIVE AIRWAY PRESSURE SETUP
1. Select a CPAP and humidification unit as shown in Figure 37.2A and identify the controls.
Record the type of unit used and the available controls on your laboratory report.
If a commercial CPAP unit is not available, a system can be assembled as shown in
Figure 37.2B.
3. Use your laboratory partner as the patient. Identify your “patient.” Introduce yourself and
your department. Explain to your partner in nonmedical terms that you are going to apply
a mask CPAP device and what is involved. Verify that your partner understands and answer
any questions or concerns. The partner should simulate a patient’s concern and fears about
having this procedure performed. You should respond appropriately.
4. Assess the “patient’s” vital signs, Spo2, breath sounds, and ventilatory status. Record your
5. Assess your lab partner for the appropriate interface. This may be done by using the
mask sizing gauge to measure your lab partner. Select the smallest mask possible that will
come close to, but not contact, the nasal bone, external nares, and upper lip, as shown in
Figure 37.3. Another choice of interface may be nasal pillows as shown in Figure 37.4.
Select the interface that maximizes comfort and minimizes leaks. Record the interface
choice and mask size on your laboratory report. Remember to explain everything to your
partner.
6. Use spacers to fill any gaps, as shown in Figure 37.5.
7. Connect the CPAP unit and humidification unit to the power source. Fill the humidifier
with distilled water.
8. Attach the headgear or straps to your partner’s head and assess for proper position of the
mask. Ensure the presence of an exhalation port (such as a Whisper Swivel®), as shown in
Figure 37.6. Confirm proper fit and comfort.
A B
Figure 37.2. Continuous positive airway pressure (CPAP) systems: (A) Commercial CPAP system with humidification unit; (B) Assembly of a CPAP system from
component parts.
2679_Ch37_625-638.indd 628 07/02/13 4:47 PM

Figure 37.3. Fitting a full-face

CPAP/BiPAP mask.
Figure 37.4. Nasal pillows.
Figure 37.5. Nasal CPAP/BiPAP mask with spacers.
9. Attach the mask to the hose, as shown in Figure 37.7.

10. Turn the CPAP unit or system on.
11. Adjust the CPAP pressure to 5 cm H2O.
12. Reassess vital signs, Spo2, breath sounds, and ventilatory status. Record your findings on
13. Based on your “patient” assessment, recommend any appropriate setting changes to the
physician.
14. Ask your partner how he or she is tolerating the pressure. Have your partner try to mouth-
breathe and talk. Record your observations on your laboratory report.
15. “Chart” the initiation of CPAP on your laboratory report as you would on a legal medical
record.
2679_Ch37_625-638.indd 629 07/02/13 4:47 PM

Figure 37.6. Mask with headgear and exhalation port.
Figure 37.7. BiPAP ventilatory support system.

(Adapted from Philips Respironics with permission.)
EXERCISE 37.3 BiPAP SETUP
1. Select a BiPAP and humidification unit, as shown in Figure 37.8. Note the various
connections and air filter locations and identify the controls. Record the type of unit and
the available controls on your laboratory report.
3. Use your laboratory partner as the patient. Identify your “patient.” Introduce yourself and
your department. Explain to your partner in nonmedical terms that you are going to apply
a mask BiPAP device and what is involved. Verify that your partner understands and
answer any questions or concerns.
4. Assess the “patient’s” vital signs, Spo2, breath sounds, and ventilatory status. Record your
2679_Ch37_625-638.indd 630 07/02/13 4:48 PM

To humidifier
Circuit
tubing
Humidifier
Bacteria filter
(optional)
Circuit tubing to
patient interface
Heater
Figure 37.8. BiPAP with humidification unit. (Adapted from Philips Respironics with permission.)
5. Using the same steps as in the CPAP exercise, determine the appropriate interface, measure
your partner for the correct size mask, and attach your partner to the unit using the
following settings:
F Mode: Spontaneous
F IPAP: 10 cm H2O
F EPAP: 6 cm H2O
F Percent IPAP: 20%
F Low-pressure alarm: 4 cm H2O
F High-pressure alarm: 15 cm H2O
F Fio2: 21% (room air)
6. Observe the pressure manometer for several breathing cycles. Determine the I:E ratio and
record the result on your laboratory report. Ask your partner whether he or she felt any
differences between breathing on a CPAP unit versus BiPAP. Record your observations on
7. Adjust the low-pressure alarm to 8 cm H2O. Note any pressure changes and other
occurrences. Record your observations on your laboratory report. Correct any malfunctions
or alarms. Record what adjustments were made on your laboratory report.
8. Loosen the mask from your lab partner. Note any pressure changes and other occurrences.
Record your observations on your laboratory report. Resecure the mask in place.
9. Change the mode to spontaneous/timed and set the rate to 14 breaths/minute.
10. Ask your partner if he or she felt any appreciable difference. Record your observations on
11. Obtain an oxygen enrichment adapter and oxygen analyzer. Place in-line as shown in
Figure 37.9.
12. Titrate low-flow oxygen until an Fio2 of 0.28 is achieved. Record the liter flow required on
NOTE: Supplemental oxygen may also be directly titrated into the mask via the oxygen
bleed-in port.
13. Adjust the unit to the following settings:
F Mode: spontaneous
F IPAP: 2 cm H2O
F EPAP: 10 cm H2O
F Percent IPAP: 20%
F Low-pressure alarm: 0 cm H2O
14. Ask your partner whether he or she felt any appreciable difference. Note any pressure
changes and other occurrences. Record your observations on your laboratory report.
15. Adjust the settings to correct any malfunctions or alarms. Record what adjustments were
made on your laboratory report.
16. Reassess the “patient’s” vital signs, Spo2, breath sounds, and ventilatory status. Record
17. Based on your “patient” assessment, recommend any appropriate setting changes to the
physician.
2679_Ch37_625-638.indd 631 07/02/13 4:48 PM

Figure 37.9. Titrating oxygen with BiPAP. (Adapted from Philips A B

Respironics with permission.)
RE F E RE N CE S
1. Kacmarek, RM, Mack, CW, and Dimas, S: The Essentials of Respiratory Care, ed. 4. Mosby, St. Louis, 2005.
2. Hess, DR: Noninvasive ventilation in neuromuscular disease: Equipment and application. Respir Care 51:896–911, 2006.
3. Hess, DR: The evidence for noninvasive positive-pressure ventilation in the care of patients in acute respiratory failure: A systematic review
of the literature. Respir Care 49:810–829, 2004.
4. Nava, S, Navalesi P, and Gregoretti C: Interfaces and humidification for noninvasive mechanical ventilation. Respir Care 54:71–82, 2009.
5. Hill, NS, and Bach, JR: Noninvasive mechanical ventilation. Respir Care Clin N Am 2:161–352, 1996.
2679_Ch37_625-638.indd 632 07/02/13 4:48 PM

Laboratory Report
CHAPTER 37: NONINVASIVE VENTILATION
Name: Date:
Data Collection
EXERCISE 37.1 Negative-Pressure Ventilator
Type of ventilator used: ________________________________________________________________________________________
Controls available: ____________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
“Patient” assessment: _________________________________________________________________________________________
____________________________________________________________________________________________________________
Observations: ________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Exhaled tidal volume: __________________________________________________________________________________________
____________________________________________________________________________________________________________
Chart the initiation of noninvasive ventilation as you would on a legal medical record:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Exhaled tidal volume with loosened cuirass: ________________________________________________________________________
2679_Ch37_625-638.indd 633 07/02/13 4:48 PM

EXERCISE 37.2 Continuous Positive Airway Pressure Setup
____________________________________________________________________________________________________________
Interface selected: ____________________________________________________________________________________________
Mask size: __________________________________________________________________________________________________
____________________________________________________________________________________________________________
Observation: _________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Chart the initiation of CPAP as you would on a legal medical record:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
EXERCISE 37.3 BiPAP Setup
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
I:E ratio: ____________________________________________________________________________________________________
(Show your work for any calculations.)
2679_Ch37_625-638.indd 634 07/02/13 4:48 PM

IPAP = 10 cm H2O; EPAP = 6 cm H2O; pressure alarm = 4 cm H2O
Observations: ________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Pressure alarm = 8 cm H2O
Observations: ________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Adjustments made: ____________________________________________________________________________________________
Observation with loose mask: ___________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Observations in the timed mode: _________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Liter flow: ___________________________________________________________________________________________________
Observations with IPAP = 2, EPAP = 10: ____________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Adjustments made: ____________________________________________________________________________________________
____________________________________________________________________________________________________________

1. What settings change would you recommend to a physician to increase the tidal volume for a patient on a
negative-pressure ventilator?
2679_Ch37_625-638.indd 635 07/02/13 4:48 PM

2. What types of patients would not be candidates for noninvasive ventilation?
3. Based on the exercises, what limitations of noninvasive ventilation did you observe?
4. Scenario 1: Mr. Pickwick has obstructive sleep apnea, and the doctor has ordered him to be placed on BiPAP at the
following settings: mode, S/T; rate, 12 breaths/minute; IPAP = 12 cm H2O; EPAP = 6 cm H2O. You enter his room,
identify yourself, and explain everything to him. You also perform a complete assessment. After applying BiPAP, you
note a drop in blood pressure and oxygen saturation.
A. What are possible causes of the drop in blood pressure and Spo2 and what changes or modifications would you
recommend?
B. What would you recommend to Mr. Pickwick for infection control in the home?
5. Scenario 2: You are a newly employed home care therapist and are visiting Mr. Pickwick for the first time. While
checking his BiPAP setup, you observe that 2 Lpm of oxygen from an oxygen concentrator is being titrated directly
into the mask.
A. How would you determine the Fio2 being delivered? Explain your answer.
B. How can you assess the adequacy of the oxygen therapy being provided?
6. You receive an order for CPAP with humidification to be setup for a patient with sleep apnea in his home. What
instructions would you give the patient concerning the use and care of the humidification unit?
2679_Ch37_625-638.indd 636 07/02/13 4:48 PM


STUDENT: DATE:
CPAP/BiPAP INITIATION (NONINVASIVE VENTILATION)

PERFORMANCE LEVEL
PERFORMANCE RATING
Evaluator: Setting:
Performance Level:
NA = Not applicable
Performance Rating:

2. Identifies the circuit components of a continuous flow noninvasive circuit and assembles:
A. 6-foot smooth bore tubing
B. Exhalation port or mask with integrated exhalation port
C. Proximal pressure tubing
D. Interface
E. Bacteria filter to machine outlet
3. Performs the required leak test (if applicable)

5. Differentiates between CPAP and BiPAP modes
6. Fills the humidifier chamber with distilled water
7. Turns the unit or system on and selects the proper mode, pressures, ramp or rise time, FIO2, and timed inspiration
8. Checks the alarm function and sets alarms
9. Positions the patient and measures the patient for the appropriate mask size
10. Uses spacers to fill any gaps
11. Attaches the mask to the hose
12. Attaches the head straps to the patient’s head; confirms proper fit and comfort
13. Evaluates waveforms to identify tidal volume, rate, pressures and flow, and air trapping or auto-PEEP
14. Adjusts the pressure(s) (CPAP, IPAP, EPAP) to conform with the physician’s order
15. Reassesses vital signs, SpO2, breath sounds, and ventilatory status
16. Determines how the patient is tolerating the pressure; readjusts the mask if necessary
17. Evaluates for an alternative interface if the patient is not tolerating the mask
FOLLOW-UP
2679_Ch37_625-638.indd 637 07/02/13 4:48 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
to modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch37_625-638.indd 638 07/02/13 4:48 PM

CHAPTER Pressure
Ventilators
INTRODUCTION With pressure-limited/volume-variable ventilators, the breath generally continues until

a preset pressure is reached. Hence, the amount of volume for each breath depends on
the set pressure as well as the patient’s compliance and airway resistance.1
In general, pressure-limited/volume-variable ventilation is not the first choice of

ventilator strategy used in the adult intensive care setting. In recent years, however,
the advancement of microprocessor ventilator technology has led to increased
acceptance of pressure-controlled, variable-flow, time-cycled ventilation.2 Additionally,
pressure ventilation still remains the first choice of ventilation in the neonatal intensive
care setting. Therefore, a thorough understanding of pressure ventilation is essential.
Beyond this and perhaps more importantly, this chapter examines the relationships
among pressure, flow, volume, and time. In this sense, it will help the respiratory care
practitioner (RCP) grasp the complexities of mechanical ventilation. By understanding
the concepts covered in this chapter, the RCP will be better prepared to initiate
ventilation and monitor patients using the more advanced modes available on
highly sophisticated equipment.
This chapter is not intended to cover pressure modes of ventilation. Although the
exercises recommend use of a microprocessor ventilator in the pressure-control setting,
the RCP should recognize that pressure-control ventilation is a type of ventilation and
should not consider this as a mode, at this point. In this sense, this material will help
prepare the RCP for a more in-depth exploration of mechanical ventilation in later
chapters.
OBJECTIVES 1. Identify the components of an adult breathing circuit.

Upon completion of this 2. Test the circuit for leaks.
3. Identify and operate the controls of a pressure-limited ventilator.
4. Initiate and monitor pressure-limited ventilation.
5. Compare the interrelationships between pressure, volume, flow, and time.
6. Relate the changes that might occur in the parameters of pressure, volume, flow, and time with
changes in compliance and resistance.
7. Chart the data related to pressure-limited ventilation in the medical record.
KEY TERMS
airway resistance pressure-limited/volume-variable ventilator wye
I:E ratio pressure ventilator
639
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Exercises
F 50-psi gas source F Lung simulator or test lungs
F Adult breathing circuits F Respirometer and adapter
F Corrugated tubing F Ventilator with pressure-limited capability
F High-pressure hose F Watch with second hand
EXERCISE 38.1 IDENTIFICATION OF AN ADULT BREATHING CIRCUIT AND LEAK

TESTING
1. Select an adult breathing circuit for a pressure-limited ventilator. Record the circuit used on
2. Examine the components shown in Figure 38.1.
3. Connect the inspiratory limb of the circuit to the ventilator outlet. Connect the expiratory
limb of the circuit to the ventilator.
4. Attach the ventilator to power sources. Your instructor will guide you through the
ventilator’s internal self-test and leak testing of the circuit. Attach the circuit outlet to the test
lung when the ventilator is ready for use.
5. Record the ventilator used, your observations, and any corrective actions on your laboratory
report.
A
Figure 38.1. (A) Double-limb adult breathing circuit.
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C H A P T E R 38 | P R ES S UR E V ENTILATOR S • 641
B
Figure 38.1.—cont’d (B) Single-limb adult breathing circuit. ([B] Courtesy of Cardinal Health, Dublin, OH.)
EXERCISE 38.2 PRESSURE, FLOW, VOLUME, AND TIME RELATIONSHIPS
1. Attach the ventilator circuit to a lung simulator or test lung as shown in Figure 38.2. Adjust
the lung simulator to normal compliance and resistance values.
2. Select the Pressure Control mode and adjust the pressure and inspiratory time according to
the chart provided in your laboratory report.
3. Observe the delivered tidal volume and inspiratory flow on the ventilator’s monitor.
4. Record your findings for tidal volume achieved and inspiratory flow in the chart provided.
5. Measure or observe monitored parameters for inspiratory and expiratory times and record
6. Observe or calculate the I:E ratio using the measured inspiratory time (TI) and expiratory
time (TE) as in the following formula and record it on your laboratory report.
I:E ratio = 1: TE / TI
7. Answer the questions in the laboratory report that pertain to the preceding exercise following
completion of observed and calculated parameters.
Figure 38.2. Attaching the circuit to a test lung.
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EXERCISE 38.3 INITIATION AND MONITORING
Given the following Mrs. Gandhi is a 45-year-old nonsmoker with a history of asthma. She is in the recovery room
information, complete the following a colon resection. She is not yet reactive and is not breathing spontaneously. She weighs
exercise as directed. Use 150 lb. You have been called to place her on a pressure ventilator until she becomes reactive.
the lung simulator as your 1. Using the formula of 6 to 8 mL/kg, set the ventilator to give the patient an appropriate tidal
patient. Your instructor volume and respiratory rate of 12 breaths/minute. Record your settings for pressure and
will show you how to flow on your laboratory report.
operate the simulator. 2. Measure the tidal volume, inspiratory time, and expiratory time, and record them on your
Depending on the brand laboratory report. Calculate the I:E ratio on your laboratory report.
of simulator, you might have 3. Simulate an increase in resistance perhaps by switching to an R20 adapter. Measure the
to change adapters or tidal volume, and observe any changes in volume and I:E ratio. Record them on your
settings in order to vary laboratory report.
compliance and airway 4. Increase the pressure until you have achieved the tidal volume in step 1. Record the pressure
resistance. Use the settings setting on your laboratory report.
on your simulator that 5. Using the flow control, adjust the inspiratory time until the I:E ratio returns to the original
correspond to the value. Record the settings and your observations on your laboratory report.
compliance and resistance 6. Return to normal resistance, perhaps by switching back to an R5 adapter. Reduce the
settings in the exercises. compliance on the right lung to 0.08 L/cm H2O (low compliance). Measure the tidal
Initially use the R5 volume, inspiratory time, and expiratory time, and record them on your laboratory report.
resistance adapters (normal Calculate the I:E ratio on your laboratory report.
resistance) and set the 7. Set the left lung to the same compliance setting as in step 6. Measure the tidal volume,
compliance of both lungs inspiratory time, and expiratory time, and record them on your laboratory report. Calculate
at 0.10 L/cm H2O (normal the I:E ratio on your laboratory report.
resistance and compliance 8. Increase the pressure until you have achieved the tidal volume in step 1. Record the pressure
settings). setting on your laboratory report.
9. Using the flow control, set an appropriate I:E ratio. Record the settings and your
10. Finally, reduce the compliance to 0.01 L/cm H2O and increase the resistance to R20.
Measure the tidal volume, inspiratory time, and expiratory time, and record them on your
laboratory report. Calculate the I:E ratio on your laboratory report.
11. Note how changes in compliance and resistance affect tidal volume, inspiratory time,
expiratory time, and I:E ratio, and discuss what changes occurred.
RE F E RE N CE S
1. Denehy, L, and Berney, S: The use of positive pressure devices by physiotherapists. Eur Respir J 17:821–829, 2001.
2. Shortall, S, and Oakes, D: Practical uses of pressure-controlled ventilation. Focus: J for Respir Care & Sleep Medicine Jan 2005.
2679_Ch38_639-646.indd 642 07/02/13 4:48 PM

Laboratory Report
CHAPTER 38: PRESSURE VENTILATORS
Name: Date:
Data Collection
EXERCISE 38.1 Identification of an Adult Breathing Circuit and Leak Testing
Ventilator used: ________________________________________________________________________________________________
Adult breathing circuit used: _____________________________________________________________________________________
Observations: _________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
EXERCISE 38.2 Pressure, Flow, Volume, and Time Relationships
NORMAL RESISTANCE AND COMPLIANCE
Adjust the pressure control level and inspiratory time percentage or inspiratory time in seconds according to the following table.
1. Record observed parameters and calculations with each pressure adjustment.
Inspiratory Time Expiratory Time

Pressure Control (cm H2O) Tidal Volume (mL) Inspiratory Time % Set (seconds) (seconds) I:E Ratio Flow Rate (Lpm)
10 33%
20 33%
30 33%
30 20%
20 20%
10 20%
2. What happened to the tidal volume when the pressure control level was increased? Explain why this happened.
3. Compare the tidal volume delivery when the pressure control is set at the same level, but inspiratory time is adjusted. How did a
change in the inspiratory time (or time percentage) affect the amount of volume delivered? Explain why this happened.
4. What effect did changes in inspiratory time (or time percentage) have on the flow rate?
5. What effect did a change in inspiratory time (or time percentage) have on the I:E ratio?
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EXERCISE 38.3 Initiation and Monitoring
Respiratory Rate of 12 Breaths/Minute
Peak pressure:____________________________________________________________________________
Peak flow: _______________________________________________________________________________
Tidal volume: _____________________________________________________________________________
Inspiratory time: __________________________________________________________________________
Expiratory time: ___________________________________________________________________________
I:E ratio (Show your work): __________________________________________________________________
High Resistance (R20)
Tidal volume: _____________________________________________________________________________
Pressure setting: __________________________________________________________________________
Flow setting: _____________________________________________________________________________
Adjusted peak pressure setting: ______________________________________________________________
Observations: ____________________________________________________________________________
Decreased Compliance Right Lung (CL 0.08 L/cm H2O)
Tidal volume: _____________________________________________________________________________
Expiratory time: ___________________________________________________________________________
Decreased Compliance Both Lungs (CL 0.08 L/cm H2O)
Tidal volume: _____________________________________________________________________________
Expiratory time: ___________________________________________________________________________
Pressure setting: __________________________________________________________________________
Flow setting: _____________________________________________________________________________
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Low Compliance and High Resistance (CL 0.01 L/cm H2O AND R20)
Tidal volume: _____________________________________________________________________________
Expiratory time: ___________________________________________________________________________
Observations: ____________________________________________________________________________

1. Given the scenario with Mrs. Gandhi, answer the following:
A. What clinical situations did increasing the airway resistance simulate?
B. What clinical situations did decreasing the compliance in the right lung simulate? In both lungs?
2. What patient assessment techniques would you use to evaluate Mrs. Gandhi’s ventilatory status?
3. Construct a sample charting note using the initial settings and data obtained in Exercise 38.3. Be sure to include all
assessment information.
4. Based on your observations and measurements:
A. What effect did increasing the resistance have on the exhaled tidal volume and I:E ratio?
B. What parameter(s) would you change to maintain adequate ventilation and I:E ratio?
C. What effect did decreasing the compliance have on the exhaled tidal volume and I:E ratio?
D. What parameter(s) would you change to maintain adequate ventilation and I:E ratio?
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2679_Ch38_639-646.indd 646 07/02/13 4:48 PM
CHAPTER Continuous
Mechanical
Ventilation
INTRODUCTION During volume-limited/pressure-variable ventilation, the breath continues until a

preset volume is reached. The amount of pressure required to deliver the preset tidal
volume will depend on the patient’s compliance and resistance. Unlike pressure-limited/
volume-variable ventilation, volume-limited ventilation will guarantee delivery of a
minimum minute ventilation regardless of changes in the patient’s lung mechanics but
may cause alveolar hyperinflation if strategies to reduce tidal volumes are not applied.1
Although pressure-limited and volume-limited ventilation have been the most common
modes used in critical care, combinations of volume and pressure ventilation, or dual
modes, are increasingly used as an alternative modality.
This chapter is intended to introduce the respiratory care practitioner (RCP) to the
initiation of volume ventilation. It will explore the relationships between pressure,
flow, volume, and time during volume ventilation. This will allow you to observe how
volume-targeted ventilation differs in breath delivery when compared to pressure-
targeted ventilation and will help you use either design to maximize the benefits and
minimize the problems with each. You must be able to apply these concepts to initiate
ventilation and monitor patients using the more advanced modes available on current
highly sophisticated equipment.2
OBJECTIVES 1. Initiate and monitor volume-limited ventilation.

Upon completion of this 2. Compare the interrelationships between pressure, volume, flow, and time.
3. Relate the changes that might occur in the parameters of pressure, volume, flow, and time with
changes in compliance and resistance.
4. Chart data related to volume-limited ventilation in the medical record.
KEY TERMS
Compressible volume volume
flow volume limited/pressure
pressure variable ventilation
time volume ventilator
647
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Exercises
F 50-psi gas source F Humidifiers (HME, cascade, and wick)
F 50-psi oxygen source F Manufacturer’s operation and maintenance
F 50-psig regulator manuals (videos if available)
F Adult breathing circuits with and without F Respirometer and adapter
exhalation valve F Sterile water
F Air compressor F Test lung or lung simulator
F Blender F Volume ventilator
F Corrugated tubing F Watch with second hand
F HEPA bacteria filter F Water traps
F High-pressure hoses F Wrench
EXERCISE 39.1 VENTILATOR ASSEMBLY
1. Select a volume ventilator, water traps, bacteria filters, humidifier, and test lung. Record the
ventilator brand and model on your laboratory report.
2. Obtain the maintenance manual for the ventilator selected. In the manual, find the
manufacturer’s recommendations for changing and cleaning of bacteria filters and fan filters,
sterilization or disinfection instructions for internal and external parts and surfaces, and
requirements for routine maintenance. Record this information on your laboratory report.
3. Locate the chronometer, if available, and record the number of hours of use on your
laboratory report.
4. Assemble the ventilator with a humidifier and water traps as shown in Figure 39.1 and
with a heat and moisture exchanger (HME) as shown in Figure 39.2. Note any difficulties
encountered while assembling the ventilator and record them on your laboratory report.
5. Repeat this exercise for each ventilator provided.
Airway temperature probe Air flow from

ventilator
To patient
Pressure tubing
To ventilator Heated humidifier

Figure 39.1. Ventilator circuit assembly with humidifier and water traps. (Courtesy of Fisher & Paykel Healthcare, Auckland, New Zealand.)
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C H A P T E R 39 | C O N T I N U O U S M E C H A NIC AL V ENTILATION • 649
Proximal
Swivel adaptor pressure line
Flex tube
To spirometer
Heat moisture
exchanger
Ventilator
Figure 39.2. Ventilator circuit assembly with
a heat and moisture exchanger (HME).
EXERCISE 39.2 IDENTIFICATION OF CONTROLS
1. On the volume ventilator selected, identify the following controls. It is important to note that
not all ventilators have the same controls, but they have several controls in common. Record
the ventilator used and the controls identified on your laboratory report.
F Tidal volume or minute volume
F Rate
F Fio2
F Flow or percent inspiratory time
F Sigh volume
F Sigh rate
F High-pressure limit
F Low-pressure limit
F Fio2 alarms
F Low-exhaled volume alarm
EXERCISE 39.3 LEAK TESTING
Use the same equipment 1. Turn all settings to the minimum or off setting.
from the previous exercises. 2. Increase the tidal volume to 400 mL.
3. Increase the high-pressure limit to 80 cm H2O or to the maximum setting.
4. Occlude the patient adapter at the wye.
5. Cycle the ventilator. Record your observations and the pressure achieved on your laboratory
report.
EXERCISE 39.4 DETERMINATION OF TUBING COMPLIANCE FACTOR

AND CALCULATION OF LOST VOLUME
Using the same volume ventilator, attach it to the test lung as in Figure 39.1 and perform the following:
1. Set the flow to the minimum setting.
2. Set the tidal volume to 300 mL.
3. Ensure that the high-pressure limit is set at the maximum.
4. Occlude the patient adapter at the wye.
5. Cycle the ventilator. Record your observations and the pressure achieved on your laboratory
report.
6. Determine the compressibility factor (CF) using the following formula:
Set VT – Observed exhaled VT / Pressure = Compressibility factor
7. Record the compressibility factor on your laboratory report.
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EXERCISE 39.5 PRESSURE, FLOW, VOLUME, AND TIME RELATIONSHIPS
1. Attach the ventilator circuit to a lung simulator or test lung. Adjust the lung simulator to
normal compliance and resistance values.
2. Select the Volume Control mode and adjust the tidal volume and peak flow according to the
chart provided in your laboratory report.
3. Observe the peak airway pressure and inspiratory time on the ventilator’s monitor.
4. Record your findings for peak airway pressure in your laboratory report.
5. Measure or observe monitored parameters for inspiratory and expiratory time and record
your findings in your laboratory report.
6. Observe or calculate the I:E ratio using the measured inspiratory time (TI) and expiratory
time (TE) as in the following formula and record it on your laboratory report.
I:E ratio = 1: TE / TI
7. Answer the questions in the laboratory report that pertain to the preceding exercise following
completion of observed and calculated parameters.
RE F E RE N CE S
1. MacIntyre, N, and Sessler, C: Are there benefits or harm from pressure targeting during lung-protective ventilation? Respir Care 55:
175–183, 2010.
2. McPherson, S: Respiratory Care Equipment, ed. 7. Mosby, St. Louis, 2004.
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Laboratory Report
CHAPTER 39: CONTINUOUS MECHANICAL VENTILATION
Name: Date:
Data Collection
EXERCISE 39.1 Ventilator Assembly
Ventilator brand and model: _________________________________
Hours of use: ____________________________________________
Difficulties encountered: _______________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
EXERCISE 39.2 Identification of Controls
(Attach a separate sheet for additional ventilators used.)
Controls identified: ____________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
EXERCISE 39.3 Leak Testing
Observations and pressure achieved: _____________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
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EXERCISE 39.4 Determination of Tubing Compliance Factor and Calculation of Lost Volume
Observed exhaled tidal volume: ______________________________
Pressure reading : _________________________________________
Observations : ________________________________________________________________________________________________
Calculated compressibility factor (CF). Show your work.
____________________________________________________________________________________________________________
EXERCISE 39.5 Pressure, Flow, Volume, and Time Relationships
Adjust the tidal volume and peak flow according to the following table.
1. Record observed parameters and calculations with each pressure adjustment.
Peak Airway Pressure Inspiratory Time Expiratory Time

Set Tidal Volume (mL) (cm H2O) Set Peak Flow (Lpm) (seconds) (seconds) I:E Ratio
400 60
600 60
800 60
800 40
600 40
400 40
2. What happened to the peak airway pressure when the tidal volume was increased? Explain why this happened.
3. Compare peak pressures when the tidal volumes are set at the same level. Did a change in the peak flow rate affect the peak
airway pressures? Explain why or why not.
4. What effect did a change in the peak flow rate have on the inspiratory time?
5. What effect did a change in the peak flow rate have on I:E ratio?

1. You have just assembled a volume ventilator and performed a leak test. The cycling pressure achieved when the wye
was occluded was only 55 cm H2O. Describe the step-by-step procedure you would use to rectify the problem.
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2. You have successfully rectified the problem in Critical Thinking Question 1. How would you communicate to the
incoming shift that this ventilator is ready for patient use?
3. Given the following data, calculate the compressible volume loss and actual VT. Show your work.
A. VT = 500 mL
CF = 4 mL/cm H2O
Peak pressure = 20 cm H2O
Lost volume = _______________ mL
Actual VT = _______________ mL
B. VT = 800 mL
CF = 2 mL/cm H2O
Lost volume = _______________ mL
Actual VT = _______________ mL
C. VT = 700 mL
CF = 3.5 mL/cm H2O
Lost volume = _______________ mL
Actual VT = _______________ mL
D. VT = 200 mL
CF = 2 mL/cm H2O
Lost volume = _______________ mL
Actual VT = _______________ mL
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2679_Ch39_647-654.indd 654 07/02/13 4:48 PM
CHAPTER Ventilator Modes
INTRODUCTION Critical care ventilators use three basic patterns of ventilation to deliver a mechanical
breath to a patient: continuous mandatory ventilation (CMV), intermittent mandatory
ventilation (IMV), and continuous spontaneous ventilation (CSV). Ventilators can achieve
these patterns by using a variety of modes made possible by microprocessor technology
incorporated into their design. In addition to common modes that have a single primary
control of pressure or volume, newer ventilators have sophisticated closed-loop control
systems that offer advanced modes capable of providing targeting schemes. These
ventilators adjust ventilation based on target values set by the clinician, or automatically
adjust based on a mathematical model or artificial-intelligence system.1 The respiratory
care practitioner (RCP) must recognize the different modes available with specific
ventilators and understand that each pattern and mode has a different goal. Is the goal to
rest the patient’s respiratory muscles, or do we allow the patient to do some work? Will
we allow the patient to breathe spontaneously as a supplement to machine breaths or as
the sole method of ventilation? Do we need to augment the patient’s spontaneous
breaths or increase the functional residual capacity (FRC)? Does the patient have difficulty
primarily with oxygenation, ventilation, or both? Should the primary control variable be
pressure, volume, or a combination of both? Should mechanical breaths be mandatory or
assisted or both? The RCP’s selection of the most appropriate ventilator mode will
address these concerns and provide synchrony between the patient and the ventilator.
The RCP also must understand how pressure, volume, flow, and time are manipulated
within each mode to optimize the patient’s outcome.
Once the RCP has selected the appropriate mode, the RCP must, in concert with the
attending physician or through the use of protocol, determine the most appropriate
values for the ventilator parameters, which include FIO2, tidal volume, and respiratory rate
(or minute ventilation), flow rate and pattern, inspiratory-to-expiratory ratios, inspiratory
or expiratory pauses, sighs, and any pressure adjuncts.
This chapter explores the common modes of mechanical ventilation and ventilator
capabilities that are typically found on most critical care ventilators. It is important to
note that although each manufacturer’s version of a ventilator mode may be similar to
another, mode names are proprietary, which can make their similarities less apparent and
can lead to confusion.2 The laboratory instructor will address these modes that have
common characteristics but different names as well as any modes that utilize targeting
schemes unique to the specific ventilator in use for these exercises. Guidelines for
initiation of ventilation and parameter selection, alarm settings, monitoring, and
discontinuance of mechanical ventilation are addressed in Chapters 41, 42, and 43.
655
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OBJECTIVES 1. Differentiate the various modes of mechanical ventilation and identify whether they provide a
Upon completion of this CMV, IMV, or CSV pattern of ventilation: control, assist/control, synchronized intermittent
chapter, you will be able to: mandatory ventilation (SIMV), pressure control and inverse I:E ratio ventilation, pressure
support, positive end-expiratory pressure (PEEP), and continuous positive airway pressure
(CPAP).
2. Given any mechanical ventilator, locate and identify each mode and adjunct parameter
available and determine how to use it.
3. Assess the limitations of each ventilator.
4. Evaluate the effects of manipulation of the various interdependent modes and adjunct
parameters.
5. Understand the goals of each mode of ventilation.
6. Recognize advanced modes incorporated on modern ventilators that utilize closed-loop control
for targeting schemes.
KEY TERMS
artificial-intelligence continuous inverse
system spontaneous mandatory breath
assisted breath ventilation parameters
closed-loop control control variable synchrony
continuous mandatory intermittent mandatory targeting schemes
ventilation (CMV) ventilation (IMV)
Exercises
F Adult breathing circuits for ventilators F Oxygen analyzer and in-line adapter
available F Respirometer
F Air compressor F Sterile water
F Blender F T-adapter with small-bore tubing connection
F Bourdon gauge and Thorpe tube flowmeters and cap
F Critical care ventilators F Test lungs and lung simulator (if available)
F HEPA bacteria filters F Watch with a second hand
F High-pressure hoses F Water traps
F Humidifiers (heat and moisture exchanger F Wrench
[HME] and heated humidifier system)
The goals of the various modes of mechanical ventilation are outlined in Table 40.1. Most critical
care ventilators can achieve all of these modes. You should perform all the exercises on a selected
ventilator and then repeat the entire set of exercises on any other available brands, taking particu-
lar notice of the differences between the brands of ventilators used.
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C H A P T E R 40 | V ENTILATOR M ODES • 657
Table 40.1 Goals of Mechanical
Mode Goal
Ventilation Modes
Control Precise VE; patient’s ventilatory drive controlled with
medication
Assist/Control Ventilator does almost all work; ventilatory muscles
rested
SIMV Patient breathes spontaneously between mandatory ven-
tilator breaths; ventilatory muscles used; also can be
used as weaning technique or to help stabilize a patient
fighting assist/control mode
Pressure support Augments the VT with a preselected amount of positive
pressure; decreases work of breathing, including that
superimposed by the artificial airway and circuitry
CPAP Patient breathes spontaneously; continuous positive
pressure gradient aids in oxygenation by increasing FRC
PEEP Not a true mode but an adjunct to exhalation; aids
oxygenation by increasing FRC
Pressure control Used when one needs to reduce the mean airway
pressure when high pressures are being used in
volume ventilation
Inverse I:E Aids in oxygenation
Airway pressure release ventilation (APRV) and bilevel Strategies to improve oxygenation and lower mean
ventilation airway pressure
EXERCISE 40.1 CONTROL AND ASSIST/CONTROL
Assemble a critical care ventilator and verify its proper function as performed in Chapter 39.
Record the type and brand of ventilators used on your laboratory report.
EXER C ISE 40 .1 .1 V OL UME C O N T R O L

1. Adjust the settings to the following:
F Mode: Assist/Control
F VT = 600 mL
F f = 15/minute
F Peak flow = 30 Lpm (or percent inspiratory time = 33%)
F Fio2 = 0.21
Make sure that all the alarms are set to the minimum/maximum settings.
2. Adjust the sensitivity to –10 cm H2O.
3. Attach the test lung to the patient wye connection.
4. Count the respiratory rate and compare it with the rate set on the machine. Record the
result on your laboratory report.
5. Observe the exhaled tidal volume and record the result on your laboratory report.
6. Squeeze the test lung several times to simulate a spontaneous inspiratory effort. Observe the
manometer. Count the rate at which you are squeezing the test lung and compare it with
the rate set on the machine. Record the results on your laboratory report and explain why
the ventilator responded in this manner.
7. Observe the exhaled VT and compare it with the displayed machine volume. Record the
9. Squeeze the test lung several times to simulate a spontaneous inspiratory effort. Listen to
the sound of the machine. Observe the manometer. Count the rate at which you are
squeezing the test lung and compare it with the rate set on the machine. Record the results
and observations on your laboratory report.
10. Observe the exhaled tidal volume and compare it with the displayed machine volume.
Record the result on your laboratory report.
11. Adjust the rate to 4 breaths/minute.
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12. Squeeze the test lung at a minimum rate of 15 breaths/minute. Listen to the sound of the
machine. Observe the manometer. Count the rate at which you are squeezing the test lung
and compare it with the rate set on the machine. Record the results and observations on
14. Stop squeezing the test lung. Wait 1 minute and observe the ventilator response. Count the
ventilator rate. Record your results and observations on your laboratory report.
16. Repeat the exercise with a second ventilator.
EXERCISE 4 0 .1 .2 P R ESSUR E CON TRO L

F Mode: Assist/Control
F PIP = 20 cm H2O
F f = 15/minute
F Inspiratory time = 33%
F Fio2 = 0.21
3. Set the test lung to simulate normal compliance. Attach the test lung to the patient wye
connection.
4. Count the respiratory rate and compare it with the rate set on the machine and record the
5. Observe the exhaled VT and record the result on your laboratory report.
6. Set the test lung to simulate decreasing compliance.
8. Return the test lung to normal compliance.
9. Increase the PIP to 30 cm H2O.
the rate set on the machine. Record the results and observations on your laboratory report.
Explain on your laboratory report why the ventilator responded in this manner.
13. Squeeze the test lung several times to simulate a spontaneous inspiratory effort. Listen to
the sound of the machine. Observe the manometer. Count the rate at which you are
squeezing the test lung and compare it with the rate set on the machine. Record the results
14. Observe the exhaled VT and compare it with the displayed machine volume. Record the
15. Adjust the rate to 4 breaths/minute.
16. Squeeze the test lung at a minimum rate of 15 breaths/minute. Listen to the sound of the
machine. Observe the manometer. Count the rate at which you are squeezing the test lung
and compare it with the rate set on the machine. Record the results and observations on
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EXERCISE 40.2 PRESSURE CONTROL INVERSE I:E RATIO
1. Using the same ventilator, set the mode control to Pressure Control. Maintain the settings as
follows:
F Inspiratory pressure = 15 cm H2O
F f = 15/minute
F Compliance = 0.05 L/cm H2O (decreased compliance)
2. Adjust the ventilator inspiratory time to an inverse I:E ratio of 2:1.
3. Connect the test lung or lung simulator to the patient wye.
4. Observe the exhaled tidal volume and record it on your laboratory report.
5. Measure the I:E ratio and record it on your laboratory report.
6. Calculate or determine the peak flow rate and record it on your laboratory report.
EXERCISE 40.3 SYNCHRONIZED INTERMITTENT MANDATORY VENTILATION
EXER C ISE 40 .3 .1 S YN CHR O N I Z E D I N T E R MI T T E N T MA N D AT O R Y V E N T I LAT I O N / V O L U M E

C ON TR O L
1. Using the same critical care ventilator, change the mode to SIMV and adjust the settings as
follows:
F VT = 600 mL
F f = 15/minute
F Fio2 = 0.21
Make sure all the alarms are set to the minimum/maximum settings.
3. Count the respiratory rate and observe the tidal volume, and record them on your
laboratory report.
the rate set on the machine. Record the results on your laboratory report.
5. Continue to squeeze the lung. Listen to the sound of the machine and compare it with the
assist/control mode. Observe the tidal volume for your manual squeezes and machine-
delivered breaths. Record the result and your observations on your laboratory report.
6. Decrease the set respiratory rate to 4 breaths/minute.
7. Squeeze the test lung to simulate a spontaneous inspiratory effort and count the rate at
which you are squeezing. Listen to the sound of the machine and compare it with step 5.
Observe and compare the spontaneous rate with the machine rate displayed. Observe and
compare the tidal volume for your manual squeezes and machine-delivered breaths. Record
8. Stop squeezing the test lung. Wait 1 minute, listen to the sound of the machine, and observe
the machine response. Record your observations on the laboratory report.
9. Reset any alarms if necessary. Resume squeezing the test lung. Observe the machine
response and record your observations on the laboratory report.
10. Compare the ventilator responses in the SIMV mode to the assist/control mode. Explain
why these differences occur on your laboratory report.
2679_Ch40_655-678.indd 659 08/02/13 4:52 PM

EXERCISE 4 0 .3 .2 S YN CHR ON IZED IN T E R MI T T E N T MA N D AT O R Y V E N T I LAT I O N / P R E S SU R E

C ON TR OL
1. Adjust the settings as follows:
F PIP = 20 cm H2O
F f = 15/minute
F Inspiratory time = 33%
F Fio2 = 0.21
Make sure all the alarms are set to the minimum/maximum settings.
3. Count the respiratory rate and observe the tidal volume, and record them on your
laboratory report.
the rate set on the machine. Record the results on your laboratory report.
5. Continue to squeeze the lung. Listen to the sound of the machine and compare it with the
assist/control mode. Observe the tidal volume for your manual squeezes and machine-
delivered breaths. Record the result and your observations on your laboratory report.
6. Decrease the set respiratory rate to 4 breaths/minute.
7. Squeeze the test lung to simulate a spontaneous inspiratory effort and count the rate at
which you are squeezing. Listen to the sound of the machine and compare it with step 5.
Observe and compare the spontaneous rate with the machine rate displayed. Observe and
compare the tidal volume for your manual squeezes and machine-delivered breaths. Record
8. Stop squeezing the test lung. Wait 1 minute, listen to the sound of the machine, and observe
the machine response. Record your observations on the laboratory report.
9. Reset any alarms if necessary. Resume squeezing the test lung. Observe the machine
response and record your observations on the laboratory report.
10. Compare the ventilator responses in the SIMV mode to the assist/control mode. Explain
why these differences occur on your laboratory report.
EXERCISE 40.4 POSITIVE END-EXPIRATORY PRESSURE/CONTINUOUS POSITIVE

AIRWAY PRESSURE
Record the type and brand of ventilator used on your laboratory report.
1. Using the same equipment, set the mode to assist/control.
F VT = 500 mL
F f = 15/minute
F Fio2 = 0.21
4. Attach the test lung and turn on the ventilator.
5. Observe and compare the pressure manometer and the filling of the test lung at the end of
inspiration and at the end of expiration. Record the pressure readings at end-inspiration
and end-expiration and your observations on your laboratory report.
6. Adjust the PEEP to 5 cm H2O.
and end-expiration and your observations on your laboratory report. Did the sensitivity
need to be adjusted?
8. Adjust the PEEP to 8 cm H2O.
and end-expiration and your observations on your laboratory report. Did the sensitivity
need to be adjusted?
10. Decrease the PEEP setting to 0.
11. Change the mode to CPAP.
12. Adjust the CPAP pressure to 5 cm H2O.
2679_Ch40_655-678.indd 660 08/02/13 4:52 PM

13. Squeeze the test lung to simulate a spontaneous breath.
14. Observe the pressure manometer and the filling of the test lung. Record the pressure reading
and your observations on your laboratory report.
15. Adjust the CPAP to 10 cm H2O.
16. Squeeze the test lung to simulate a spontaneous breath. Count the respiratory rate and
record it on your laboratory report.
and end-expiration and your observations on your laboratory report.
18. Stop squeezing the test lung. Wait 1 minute and observe the machine response, rate, and
tidal volume. Record your results and observations on your laboratory report. Explain on
your laboratory report why the ventilator responded as it did.
EXERCISE 40.5 PRESSURE SUPPORT MODE
Record the type and brand of ventilator used on your laboratory report.
EXER C ISE 40 .5 .1 S YN CHR O N I Z E D I N T E R MI T T E N T MA N D AT O R Y V E N T I LAT I O N W I T H

P R ESSU R E S U P P O R T
1. Using the same equipment, modify the mode to activate pressure support with the SIMV
mode.
2. Maintain the settings as:
F VT = 600 mL
F f = 4/minute
F Fio2 = 0.21
4. Adjust the pressure support level to 5 cm H2O.
5. Squeeze the test lung to simulate a spontaneous inspiratory effort and count the respiratory
rate. Observe the tidal volume and manometer pressure readings for your manual squeezes
and machine-delivered breaths. Record the results on your laboratory report.
6. While still squeezing the test lung, observe the pressure manometer. Listen to the sound of
the machine. Compare the sound of the machine during a spontaneous breath in SIMV with
pressure support with a spontaneous breath in SIMV without pressure support. Record the
pressure reading and your observations on your laboratory report.
7. Increase the pressure support to 10 cm H2O.
8. Squeeze the test lung to simulate a spontaneous inspiratory effort.
9. Continue to squeeze the lung and count the respiratory rate. Listen to the sound of the
machine and compare it with step 6. Observe the tidal volume for your manual squeezes
and machine-delivered breaths. Record the results and your observations on your
laboratory report.
EXER C ISE 40 .5 .2 P R ESSU R E S U P P O R T

1. Using the same equipment, modify the mode to activate pressure support without SIMV.
This may require you to consult the operation manual to determine how this is achieved on
a given ventilator. It may require the use of the CPAP mode.
2. Adjust the pressure support level to 0 cm H2O. If the CPAP mode is required, make sure
that the CPAP or PEEP pressure is set at zero.
3. Squeeze the test lung to simulate a spontaneous inspiratory effort. Observe the rate and
tidal volume for your manual squeezes and machine-delivered breaths. Record the results
4. While still squeezing the test lung, observe the pressure manometer. Listen to the sound of
the machine. Record the pressure reading and your observations on your laboratory report.
2679_Ch40_655-678.indd 661 08/02/13 4:52 PM

6. Squeeze the test lung to simulate a spontaneous inspiratory effort. Continue to squeeze the
lung. Listen to the sound of the machine and compare it with step 4. Observe the rate and
tidal volume for your manual squeezes. Record the results and your observations on your
laboratory report.
8. Squeeze the test lung to simulate a spontaneous inspiratory effort. Listen to the sound of
the machine and compare it with step 4. Observe the rate and tidal volume for your manual
squeezes. Record the results and your observations on your laboratory report.
9. Stop squeezing the test lung. Wait 1 minute and observe the rate and tidal volume. Observe
the machine response. Record your results and observations on your laboratory report.
EXERCISE 4 0 .5 .3 P R ESSUR E SUP P ORT W I T H C O N T I N U O U S P O S I T I V E A I R WAY P R E SS U R E

1. Maintain the ventilator in the pressure support mode as in Exercise 40.5.2. Set the pressure
support to 10 cm H2O.
2. Squeeze the test lung to simulate a spontaneous inspiratory effort. Continue to squeeze the
lung. Listen to the sound of the machine. Observe the rate, tidal volume, and filling of the
test lung for your manual squeezes. Record the results and your observations on your
laboratory report.
3. Adjust the CPAP to 5 cm H2O.
4. Continue to squeeze the lung. Listen to the sound of the machine and compare it with step 2.
Observe the rate, tidal volume, and filling of the test lung for your manual squeezes. Record
the results and your observations on your laboratory report.
EXERCISE 40.6 ADVANCED MODES USING TARGETING SCHEMES
Mastering the basic patterns of ventilator support using traditional modes that have one primary
controller is just the beginning of understanding mechanical ventilation. Depending on the venti-
lators available in your laboratory, you may find modes that sound very complicated and there-
fore may be intimidating. It would be impossible to name them all in the content of this chapter,
so your goal should be to familiarize yourself with the modes available on the ventilators you are
likely to use in the laboratory or hospital setting (Table 40.2). This exercise may be completed
without the use of a ventilator.
1. Select and research a ventilator that provides modes using any of the targeting schemes listed
below:
F Dual targeting
F Servo targeting
F Automatic targeting
F Intelligent targeting
Record the type/brand of ventilator on your laboratory report and identify which type(s) of
targeting schemes are available for each of the advanced mode(s).
2. Describe how the type of targeting works to create an advanced mode. Your instructor may
divide the class into discussion groups and have each group orally report on how targeting
works to create an advanced mode.
3. Explain what parameters require settings by the clinician and give an example of a starting
point or range.
4. Identify the goals for selecting this type of advanced mode.
5. Answer the questions regarding targeting schemes on your laboratory report.
2679_Ch40_655-678.indd 662 08/02/13 4:52 PM

Table 40.2 Description of
Targeting Scheme Description Advanced Modes Ventilator
Targeting Schemes and
Advanced Modes of Ventilation Dual targeting Ventilator controller can Volume Control with Pmax Dräger Evita® XL
switch between two vari-
ables (pressure and vol-
ume) during a single
inspiration
Volume Control Assist CareFusion Avea®
Control
Servo targeting Ventilator output follows a Proportional Assist Ventila- Puritan Bennett® 840™
varying input in which an tion (PAV) Plus
airway pressure signal
(volume, flow, or diaphrag-
matic electrical) is used to
detect patient effort and
uses feedback to adjust a
variable
Neurally Adjusted Ventila- Servo-i®
tory Assist
Adaptive targeting Allows the ventilator to ad- Pressure Regulated Servo-i®
just system parameters in Volume Control
response to varying patient
conditions (pressure is ad-
justed between breaths to
achieve a target tidal vol-
ume) using set points
VC+ Puritan Bennett® 840™
Intelligent targeting Artificial intelligence that SmartCare/PS Dräger Evita® XL
relies on a complex rule-
based expert system or
mathematical model to
automatically make
adjustments
This table includes a small sampling of proprietary mode names and their associated ventilators. It is not intended to
represent a complete list of the available advanced modes of ventilation and ventilator manufacturers.
R E FE R E N C E S
1. Chatburn, RL, and Mireles-Cabodevila, E: Closed-loop control of mechanical ventilation: Description and classification of targeting
schemes. Respir Care 56(1): 85–98, 2011.
2. Pierson, D: Patient-ventilator interaction. Respir Care 56 (2): 214–228, 2011.
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2679_Ch40_655-678.indd 664 08/02/13 4:52 PM
Laboratory Report
CHAPTER 40: VENTILATOR MODES
Name: Date:
Data Collection
Attach a separate paper for each exercise if additional ventilators are used.
EXERCISE 40.1 Control and Assist/Control
E X E R C IS E 40 . 1. 1 V O L U ME C O NTROL
VENTILATOR 1. Type and brand: __________________________________________________
ASSIST/CONTROL RATE OF 15
VT = 600; f = 15/minute; Peak flow = 30 Lpm; FIO2 = 0.21
Sensitivity: –10 cm H2O
Respiratory rate: _____________________________________________________________
Exhaled VT: __________________________________________________________________
Manometer observation and respiratory rate: _______________________________________________________________________
____________________________________________________________________________________________________________
Explain why the ventilator responded in this manner: _________________________________________________________________
____________________________________________________________________________________________________________
Exhaled VT: __________________________________________________________________
____________________________________________________________________________________________________________
Exhaled VT: __________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Exhaled VT: __________________________________________________________________
2679_Ch40_655-678.indd 665 08/02/13 4:52 PM

Squeezing Stopped
Observations and rate: _________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Exhaled VT: __________________________________________________________________
VT = 600; f = 15/minute; Peak flow = 30 Lpm; FIO2 = 0.21
Respiratory rate: _____________________________________________________________
Exhaled VT: __________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Exhaled VT: __________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Exhaled VT: __________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Exhaled VT: __________________________________________________________________
Squeezing Stopped
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Exhaled VT: __________________________________________________________________
E XE RCI SE 4 0 .1 . 2 P R E S S U R E C O N T R O L
PIP = 20 cm H2O; f = 15/minute; Inspiratory time = 33%; FIO2 = 0.21
2679_Ch40_655-678.indd 666 08/02/13 4:52 PM

Respiratory rate: ______________________________________________________________
Exhaled VT (normal compliance): _________________________________________________
Exhaled VT (decreasing compliance): ______________________________________________
PIP: 30 cm H2O
Exhaled VT: __________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Exhaled VT: __________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Exhaled VT: __________________________________________________________________
Squeezing Stopped
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Exhaled VT: __________________________________________________________________
What type of patient conditions are simulated by the most compliant settings? _____________________________________________
____________________________________________________________________________________________________________
What type of patient conditions are simulated by the least compliant settings? _____________________________________________
____________________________________________________________________________________________________________
How does the lung compliance affect the I:E ratio? Why? ______________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
VENTILATOR 2: Type and Brand: _________________________________________________
2679_Ch40_655-678.indd 667 08/02/13 4:52 PM

Exhaled VT (normal compliance): _________________________________________________
Exhaled VT (decreasing compliance): ______________________________________________
PIP: 30 cm H2O
Exhaled VT: __________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Exhaled VT: __________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Exhaled VT: __________________________________________________________________
Squeezing Stopped
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Exhaled VT: __________________________________________________________________
EXERCISE 40.2 Pressure Control Inverse I:E Ratio Ventilation
Inspiratory pressure = 15 cm H2O; f = 15/minute; Compliance = 0.05 L/cm H2O (decreased compliance)
Exhaled VT: __________________________________________________________________
I:E ratio: ____________________________________________________________________
Peak flow rate: _______________________________________________________________
2679_Ch40_655-678.indd 668 08/02/13 4:52 PM

What precautions must be taken when using this mode of ventilation? Why? ______________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Inspiratory pressure = 15 cm H2O; f = 15/minute; Compliance = 0.05 L/cm H2O (decreased compliance)
Exhaled VT: __________________________________________________________________
I:E ratio: ____________________________________________________________________
Peak flow rate: _______________________________________________________________
EXERCISE 40.3 Synchronized Intermittent Mandatory Ventilation
E X E R C IS E 40 . 3. 1 S Y NC H R O N IZ ED IN TERMITTEN T MAN DATORY VEN TIL ATION /VOL UME C ONTROL
VT = 600 mL; f = 15/minute; Peak flow = 30 Lpm (or percent inspiratory time = 33%); FIO2 = 0.21
Exhaled VT: __________________________________________________________________
____________________________________________________________________________________________________________
Spontaneous exhaled VT: _______________________________________________________
Machine exhaled VT: ___________________________________________________________
Manometer observation: _______________________________________________________
SIMV RATE 4/MINUTE
Spontaneous respiratory rate: ___________________________________________________
Machine rate: ________________________________________________________________
Machine VT: _________________________________________________________________
Squeezing Stopped
Observations: ________________________________________________________________________________________________
____________________________________________________________________________________________________________
Squeezing Resumed
Observations: ________________________________________________________________________________________________
____________________________________________________________________________________________________________
Explain why the differences between the SIMV and the assist/control modes occur: ________________________________________
____________________________________________________________________________________________________________
2679_Ch40_655-678.indd 669 08/02/13 4:52 PM

Exhaled VT: __________________________________________________________________
____________________________________________________________________________________________________________
Manometer observation: _______________________________________________________
SIMV Rate 4/minute
Machine rate: ________________________________________________________________
Machine VT: _________________________________________________________________
Squeezing Stopped
Observations: ________________________________________________________________________________________________
____________________________________________________________________________________________________________
Squeezing Resumed
Observations: ________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
E XE RCI SE 4 0 .3 . 2 S Y NC H R O N IZ E D INT E R MITTEN T MAN DATORY VEN TIL ATION /PRESSURE CON TROL
Exhaled VT: __________________________________________________________________
____________________________________________________________________________________________________________
SIMV Rate 4/minute
Machine rate: ________________________________________________________________
2679_Ch40_655-678.indd 670 08/02/13 4:52 PM

Machine VT: _________________________________________________________________
Squeezing Stopped
Observations: ________________________________________________________________________________________________
Squeezing Resumed
Observations: ________________________________________________________________________________________________
____________________________________________________________________________________________________________
Exhaled VT: __________________________________________________________________
____________________________________________________________________________________________________________
SIMV Rate 4/minute
Machine rate: ________________________________________________________________
Machine VT: _________________________________________________________________
Squeezing Stopped
Observations: ________________________________________________________________________________________________
Squeezing Resumed
Observations: ________________________________________________________________________________________________
____________________________________________________________________________________________________________
EXERCISE 40.4 Positive End-Expiratory Pressure/Continuous Positive Airway Pressure
ASSIST/CONTROL
Manometer observation and initial pressure readings: ________________________________________________________________
____________________________________________________________________________________________________________
2679_Ch40_655-678.indd 671 08/02/13 4:52 PM

PEEP 5 cm H2O
Manometer observation and pressure readings: _____________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Did the sensitivity need to be adjusted? ____________________________________________
PEEP 8 cm H2O
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
CPAP MODE
CPAP 5 cm H2O
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
CPAP 10 cm H2O
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Squeezing Stopped
Pressure reading and observations: ______________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
VT: _________________________________________________________________________
Explain why the ventilator responded as it did: ______________________________________________________________________
____________________________________________________________________________________________________________
Identify what clinical condition this exercise is supposed to simulate: ____________________
ASSIST/CONTROL
Manometer observation and initial pressure readings: ________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
2679_Ch40_655-678.indd 672 08/02/13 4:52 PM

PEEP 5 cm H2O
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
PEEP 8 cm H2O
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
CPAP MODE
CPAP 5 cm H2O
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
CPAP: 10 cm H2O
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Squeezing Stopped
Pressure reading and observations: ______________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
VT: _________________________________________________________________________
Explain why the ventilator responded as it did: ______________________________________________________________________
____________________________________________________________________________________________________________
Identify what clinical condition this exercise is supposed to simulate: ____________________
EXERCISE 40.5 Pressure Support Mode
E X E R C IS E 40 . 5. 1 S Y NC H R O N IZ ED IN TERMITTEN T MAN DATORY VEN TIL ATION W ITH PRESSURE SUPPORT
2679_Ch40_655-678.indd 673 08/02/13 4:52 PM

Pressure Support: 5 cm H2O
SIMV respiratory ƒ: ____________________________________________________________
Exhaled machine VT: ___________________________________________________________
Machine peak pressure: ________________________________________________________
Spontaneous respiratory ƒ: _____________________________________________________
Spontaneous peak pressure: ____________________________________________________
Observations: ________________________________________________________________________________________________
____________________________________________________________________________________________________________
SIMV ƒ: _____________________________________________________________________
Spontaneous ƒ: _______________________________________________________________
Observations: ________________________________________________________________________________________________
____________________________________________________________________________________________________________
SIMV respiratory ƒ: ____________________________________________________________
Spontaneous respiratory ƒ: _____________________________________________________
Observations: ________________________________________________________________________________________________
____________________________________________________________________________________________________________
SIMV ƒ: _____________________________________________________________________
Spontaneous ƒ: _______________________________________________________________
2679_Ch40_655-678.indd 674 08/02/13 4:52 PM

Observations: ________________________________________________________________________________________________
____________________________________________________________________________________________________________
E X E R C IS E 40 . 5. 2 P R E S S U R E S UPPORT
ƒ: __________________________________________________________________________
VT: _________________________________________________________________________
____________________________________________________________________________________________________________
ƒ: __________________________________________________________________________
VT: _________________________________________________________________________
____________________________________________________________________________________________________________
ƒ: __________________________________________________________________________
VT: _________________________________________________________________________
____________________________________________________________________________________________________________
Squeezing Stopped
ƒ: __________________________________________________________________________
VT: _________________________________________________________________________
Observations: ________________________________________________________________________________________________
ƒ: __________________________________________________________________________
VT: _________________________________________________________________________
____________________________________________________________________________________________________________
ƒ: __________________________________________________________________________
VT: _________________________________________________________________________
____________________________________________________________________________________________________________
2679_Ch40_655-678.indd 675 08/02/13 4:52 PM

ƒ: __________________________________________________________________________
VT: _________________________________________________________________________
____________________________________________________________________________________________________________
Squeezing Stopped
ƒ: __________________________________________________________________________
VT: _________________________________________________________________________
Observations: ________________________________________________________________________________________________
E XE RCI SE 4 0 .5 . 3 P R E S S U R E S U P P O R T W IT H CON TIN UOUS POSITIVE AIRWAY PRESSURE
CPAP: 0 cm H2O; Pressure support: 10 cm H2O
ƒ: __________________________________________________________________________
VT: _________________________________________________________________________
Observation of test lung: _______________________________________________________________________________________
____________________________________________________________________________________________________________
ƒ: __________________________________________________________________________
VT: _________________________________________________________________________
____________________________________________________________________________________________________________
What is the effect of pressure support on the spontaneous exhaled volumes as compared with SIMV without pressure support
or CPAP without pressure support? _______________________________________________________________________________
____________________________________________________________________________________________________________
What is the best way to determine the ideal pressure support setting? ___________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
ƒ: __________________________________________________________________________
VT: _________________________________________________________________________
____________________________________________________________________________________________________________
2679_Ch40_655-678.indd 676 08/02/13 4:52 PM

ƒ: __________________________________________________________________________
VT: _________________________________________________________________________
____________________________________________________________________________________________________________
EXERCISE 40.6 Advanced Modes Using Targeting Schemes
What advanced mode(s) are available on this ventilator? ______________________________________________________________
____________________________________________________________________________________________________________
What is the targeting scheme used with the advanced mode(s) listed above? ______________________________________________
____________________________________________________________________________________________________________
What parameters must be set when selecting the advanced mode(s) listed above? Give an example of a starting point or range.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Give an example of a clinical situation in which you would suggest the use of this advanced mode(s) listed above. ________________
____________________________________________________________________________________________________________
What advanced mode(s) are available on this ventilator? ______________________________________________________________
____________________________________________________________________________________________________________
What is the targeting scheme used with the advanced mode(s) listed above? ______________________________________________
____________________________________________________________________________________________________________
Describe how this type of targeting works to create an advanced mode. _________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
What parameters must be set when selecting the advanced mode(s) listed above? Give an example of a starting point or range.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Give an example of a clinical situation in which you would suggest the use of this advanced mode(s) listed above. ________________
____________________________________________________________________________________________________________
2679_Ch40_655-678.indd 677 08/02/13 4:52 PM


1. Based on the data you collected during the laboratory exercises, do the following:
A. Contrast the major differences of each brand of ventilator utilized.
B. Discuss possible advantages and disadvantages of these differences. Relate these to effects on the quality of
patient care and patient comfort, ease of use for the practitioner, and cost effectiveness (may require
additional investigation and a literature search).
2. Why is selection of mode important during initiation and throughout the course of mechanical ventilation?
3. What is the purpose of using modes that control or limit pressure delivery with each breath?
4. Do you feel ventilators that offer advanced modes with artificial intelligence systems are a necessary choice for patients
receiving ventilator support?
2679_Ch40_655-678.indd 678 08/02/13 4:52 PM

CHAPTER Ventilator
Initiation
INTRODUCTION Now that the types of ventilators, ventilator modes, available parameters, and their
interrelationships have been discussed, we can explore the art of ventilator initiation.
Although guidelines have been established for initial settings, the respiratory care
practitioner (RCP) must assess each patient individually and select the appropriate
ventilator mode and parameters to achieve the optimal patient outcomes. This requires a
prerequisite and comprehensive understanding of anatomy, physiology, pathophysiology,
and fundamentals of respiratory care such as gas administration and airway management.
Additionally, the use of protocols for ventilator initiation and modifications will continue
to be an accepted approach to ventilator support.1
Once the RCP has determined the initial ventilator settings, the RCP must select the
corresponding alarm parameters to ensure patient safety. It is extremely important that
the RCP be able to set these parameters appropriately and understand the implications of
the alarm limits. Although different ventilators have different alarm systems, there are
certain alarms that are basic to any ventilator.2,3 Mechanical ventilation has many hazards
and complications. By appropriately adjusting ventilator settings and alarm parameters
to meet individual patient needs, the RCP can minimize iatrogenic complications.
OBJECTIVES 1. Practice communication skills needed for the initiation of mechanical ventilation.
Upon completion of this 2. Determine the location of available alarms on critical care and home care ventilators.
3. Given patient scenarios, determine the most appropriate mode of ventilation, tidal volume,
respiratory rate, Fio2, peak flow rate or percent inspiratory time, I:E ratio, and pressure
adjuncts, and initiate ventilation using critical care and home care ventilators.
4. Given sample protocols and algorithms, determine the appropriate initial setting for mode of
ventilation and parameters based on the patient scenarios provided.
5. Given the parameters selected in the scenarios, appropriately set the alarms.
6. Make recommendations and modifications to the ventilator settings based on patient
assessment and data collection.
8. Change the ventilator circuit, ensuring physical integrity and proper function with minimal
risk or harm to the patient and health-care provider.3
KEY TERMS
algorithm iatrogenic protocol
679
2679_Ch41_679-698.indd 679 07/02/13 4:48 PM

Exercises
F Air compressor F Spring-loaded PEEP valve
F Blender F Sterile water
F Bourdon gauge and Thorpe tube flowmeters F T-adaptor with small-bore tubing connection
F HEPA bacteria filters and cap
F High-pressure hoses F Test lungs and lung simulator (if available)
F Hospital bed F Volume ventilators
F Humidifiers (heat and moisture exchanger F Watch with a second hand
[HME] and heated systems) F Water traps
F Intubated or tracheostomized airway F Wrench
management trainer
EXERCISE 41.1 SETTING ALARM PARAMETERS
Not all ventilators have the same number and types of alarms. Record the manufacturer, model of
the available ventilator, and the alarm parameters on your laboratory report.
EXERCISE 4 1 .1 .1 F I O 2 or Gas Pres sure A la rms

Obtain a critical care 1. Observe the ventilator panel and determine what type of ventilator Fio2 alarm or gas
ventilator. Assemble the pressure alarm is present. You may have to consult the manufacturer’s manual. Record the
ventilator as in previous available alarms on your laboratory report.
exercises. Be sure to check 2. Connect the oxygen high-pressure hose to a Bourdon gauge or Thorpe tube flowmeter
the unit for proper function instead of a 50-psig oxygen source. Adjust the flow rate to 8 Lpm.
and correct any malfunctions 3. Set the ventilator parameters as follows:
before use. Mode = Assist/Control
f = 10/minute
VT = 500 mL
Fio2 = 0.50
Peak flow = 40 Lpm (or percent inspiratory time = 33%)
Make sure that all alarm parameters are still set at minimum/maximum.
4. Turn on the ventilator and connect it to a test lung or lung simulator.
5. If the ventilator does not have a built-in oxygen analyzer, place one in-line.
6. Set the Fio2 alarm 5% lower than the Fio2 set on the ventilator.
7. Analyze the Fio2 and observe the ventilator for any activated alarms. Record the FIO2
analyzed and observations of alarm status on your laboratory report.
8. Adjust the flow rate to 15 Lpm.
9. Set the ventilator parameters as follows:
Mode = Assist/Control
f = 20/minute
VT = 700 mL
Fio2 = 1.0
Make sure that all alarm parameters are still set at the minimum/maximum settings.
10. Analyze the Fio2 and observe the ventilator for any activated alarms. Record the FIO2
analyzed and observations of alarm status on your laboratory report.
2679_Ch41_679-698.indd 680 07/02/13 4:48 PM

C H A P T E R 41 | V E N TILATOR INITIATION • 681
11. Turn the ventilator off. Disconnect the high-pressure hose and connect it to a 50-psig gas
source.
12. Turn the ventilator on. Analyze the Fio2 and observe the ventilator for any activated
alarms. Record the FIO2 analyzed and observations of alarm status on your laboratory
report.
EXER C ISE 41 .1 .2 HIGH-PR E S S U R E / LO W-P R E S S U R E A LA R MS

1. Using the same ventilator as in Exercise 41.1.1, set the ventilator parameters as follows:
f = 12/minute
VT = 700 mL
Fio2 = 0.21
2. Turn on the ventilator and connect it to a test lung or lung simulator.
3. Observe the system pressure on the manometer or digital display and the exhaled tidal
volume, and record the pressure and exhaled tidal volume on your laboratory report.
4. Set the high-pressure limit 10 cm H2O above the observed system pressure2 and record the
setting on your laboratory report.
5. If available, set the low-pressure limit 10 cm H2O below the observed system pressure2 and
record the setting on your laboratory report.
6. Completely occlude the wye with your finger. Observe the pressure manometer and exhaled
tidal volume, and record your observations and the alarms activated on your laboratory
report.
7. Remove your finger and leave the circuit wye open. Observe the pressure manometer and
exhaled tidal volume, and record your observations and the alarms activated on your
laboratory report.
8. Reconnect the ventilator to the test lung.
EXER C ISE 41 .1 .3 LOW EX H A LE D V O LU ME A LA R MS

1. Using the same ventilator, set the exhaled tidal volume alarm 100 to 150 mL lower than the
exhaled tidal volume. If a low exhaled minute volume is available, set it by calculating a
minute ventilation that has tidal volumes 100 to 150 mL less than the delivered tidal volume.
Record these settings on your laboratory report.
2. Completely occlude the wye with your finger. Observe the pressure manometer and exhaled
tidal volume, and record your observations and the alarms activated on your laboratory
report.
3. Remove your finger and the leave circuit wye open. Observe the pressure manometer and
exhaled tidal volume, and record your observations and the alarms activated on your
laboratory report.
4. Reconnect the ventilator to the test lung.
5. Change the following parameters:
Mode = SIMV
f = 6/minute
6. Squeeze the test lung to simulate spontaneous breathing at a rate of 6 breaths/minute, for a
total rate of 12 breaths/minute.
7. Observe the ventilator and record your observations and the alarms activated on your
laboratory report.
8. Readjust the alarms appropriately, if needed, and record the adjusted alarm settings on your
laboratory report.
EXER C ISE 41 .1 .4 OTHER V E N T I LAT O R A LA R MS

From the information gathered at the start of the exercises, set any of the other available alarm
parameters and record them on your laboratory report. Remember that some of these choices will
depend on the patient’s clinical condition. Be prepared to defend the rationale used to determine
your selections. Repeat the exercise with a second ventilator.
2679_Ch41_679-698.indd 681 07/02/13 4:48 PM

EXERCISE 41.2 VENTILATOR INITIATION
Given the following Table 41.1 Guidelines for

Patient Type Rate VT
scenarios, select the mode Initial Ventilator Setting
and initial ventilator settings Selection Adults
that you feel are appropriate. Normal lungs 12–16 8–10 mL/kg
Be sure to set the alarms as
Neuromuscular disease 8–12 10–12 mL/kg
well. Refer to Table 41.1
to aid in your selection. Obstructive lung disease 10–12 8–10 mL/kg
Each scenario should be Acute restrictive disease 15–35 6–8 mL/kg
performed on all critical care Children
ventilators available in the
laboratory. 8–16 yr 20–30 8–10 mL/kg
0–8 yr 25–35 6–8 mL/kg
Adapted from Wilkins, R et al (eds): Egan’s Fundamentals of Respiratory Care, ed 9. Mosby,

St. Louis, 2009, p. 1060.
SCENARIO 1
You have been called to the trauma room. Mr. Scott is a 20-year-old, 150-lb, 5 ft 6 in., unre-
strained driver of an automobile involved in a motor vehicle collision (MVC). He is unconscious
and apneic with multiple rib fractures. He is already intubated with an 8.0-mm-ID endotracheal
(ET) tube. The resident asks you to determine the initial ventilator settings.
1. Select the initial ventilator settings and record them on your laboratory report.
2. Evaluate the patient by performing the following:
Vital signs
Physical assessment of the chest
Auscultation
Suctioning
Record what you would expect to find for the preceding parameters on your laboratory report.
3. Set the alarm parameters and record them on your laboratory report.
SCENARIO 2
Ms. Fumo is a 70-year-old, 100-lb, 5 ft 2 in., well-known COPD patient. She was admitted to the
emergency department (ED) with fever, dyspnea, and productive cough. Over the past several
hours, her dyspnea has worsened and she has become lethargic. Her arterial blood gases (ABGs)
on 2 L of nasal oxygen reveal the following:
F pH = 7.18
F Paco2 = 77 mm Hg
F Pao2 = 52 mm Hg
Her attending physician orders her intubated and asks for your recommendations for ventilator
settings.
Vital signs
Auscultation
Suctioning
Record what you would expect to find for the preceding parameters on your laboratory report.
3. Set the alarm parameters, and record them on your laboratory report.
SCENARIO 3
Ms. Hoey is a 27-year-old, 90-lb, 5 ft 4 in., HIV-positive patient admitted with fever, dyspnea,
and cough. A chest x-ray reveals bilateral pneumonia. Stat ABGs are drawn on a nonrebreather
mask. Her vital signs are as follows:
F pH = 7.48
F Paco2 = 32 mm Hg
2679_Ch41_679-698.indd 682 07/02/13 4:48 PM

F Pao2 = 48 mm Hg
F Pulse = 120/minute
F Respiratory rate = 32/minute and labored
F Blood pressure = 110/60
Vital signs
Auscultation
Suctioning
Record what you would expect to find for the preceding parameters on your laboratory
report.
S C EN AR IO 4
You are the only RCP on duty. There was a cardiac arrest in the ED and the patient must be
placed on a ventilator. Mrs. Raju is 65 years old, weighs 195 lb, is 5 ft 7 in. tall, and has an
extensive cardiac history. She is intubated with an 8.0-mm-ID ET tube. She is currently apneic.
Her ABGs were drawn during the code while being manually ventilated with 1.0 Fio2 and are
as follows:
F pH = 7.32
F Paco2 = 33 mm Hg
F Pao2 = 122 mm Hg
Vital signs
Auscultation
Suctioning
Record what you would expect to find for the preceding parameters on your laboratory
report.
EXERCISE 41.3 CIRCUIT CHANGES4
To simulate the conditions 1. Set the ventilator to the following parameters:

in the clinical setting, Mode = Control
position an intubated or f = 15
tracheostomized airway VT = 600 mL
management trainer, if Fio2 = 0.40
available, in a hospital bed. 2. Gather the necessary equipment to perform a complete ventilator circuit change.
Have your laboratory partner 3. Assemble the equipment as completely as possible.
count how many breaths are 4. Place the assembled circuit on the bed with the wye placed aseptically proximal to the
missed during the circuit “patient.” Place the other ends proximal to their corresponding connections on the
change. ventilator as shown in Figure 41.1.
5. Silence the alarms.
6. Adjust the Fio2 on the ventilator to hyperoxygenate the “patient” before disconnection.
7. Instruct your partner to hold his or her breath starting at the time of “patient”
disconnection and to continue breath holding until the “patient” is reconnected.
8. Quickly disconnect the circuit from the patient wye.
9. Quickly disconnect the other circuit connections from the ventilator.
10. Quickly attach the ends of the new circuit to the corresponding connections on the
ventilator.
11. Rapidly assess the circuit for leaks and ensure ventilator function.
12. Reconnect the “patient” to the ventilator circuit. Instruct your partner to resume breathing.
13. Observe the pressure manometer and exhaled volumes.
14. Readjust the Fio2 and reset the alarms.
15. Determine the number of breaths lost by the “patient” and the total time to complete the
circuit change. Record the number of breaths and time taken on your laboratory report.
Record your partner’s impressions of his or her breath-holding experience.
2679_Ch41_679-698.indd 683 07/02/13 4:48 PM

Circuit to be changed
New circuit
Figure 41.1. Changing a ventilator circuit.
RE F E RE N CE S
1. Kacmarek, R, Barnes, T, and Walton, J: Creating a vision for respiratory care in 2015 and beyond. Respir Care 54(3):375–389, 2009.
2. Chang, DW: Clinical Application of Mechanical Ventilation, ed. 2. Delmar, Albany, 2001, p. 185.
3. Pilbeam, S: Mechanical Ventilation: Physiological and Clinical Applications, ed. 4. Mosby, St. Louis, 2006, p. 106.
4. American Association for Respiratory Care: The AARC clinical practice guideline: Care of the ventilator circuit and its relation to
ventilator-associated pneumonia. Respir Care 48:869–879, 2003.
2679_Ch41_679-698.indd 684 07/02/13 4:48 PM

Laboratory Report
CHAPTER 41: VENTILATOR INITIATION
Name: Date:
Data Collection
EXERCISE 41.1 Setting Alarm Parameters
VENTILATOR 1. Type and brand: ______________________________________
Alarm parameters available: ____________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Alarm parameters available: ____________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
E X E R C IS E 41 . 1. 1 F I O 2 o r G a s Pres s ure Al arm s
FIO2 or gas pressure alarms available: _____________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
FIO2 or gas pressure alarms available: _____________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
2679_Ch41_679-698.indd 685 07/02/13 4:48 PM

CONNECTION TO A FLOWMETER
Flow = 8 Lpm; f = 10; VT = 500 mL; FIO2 = 0.50; PEFR = 40 Lpm
FIO2 analyzed: ____________________________________________________
Observations: ________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
FIO2 analyzed: ____________________________________________________
Observations: ________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
FIO2 analyzed: ____________________________________________________
Observations: ________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
FIO2 analyzed: ____________________________________________________
Observations: ________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
CONNECTION TO 50-PSIG SOURCE
FIO2 analyzed: ____________________________________________________
Observations: ________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
FIO2 analyzed: ____________________________________________________
Observations: ________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
2679_Ch41_679-698.indd 686 07/02/13 4:48 PM

Explain why the observations made in this exercise occurred. __________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
What can you conclude regarding the relationships between pressures, flows, and FIO2? _____________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
How does this affect the ventilator setup? __________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
E X E R C IS E 41 . 1. 2 H IG H -P R E S S URE/L OW-PRESSURE AL ARMS
f = 12; VT = 700 mL; FIO2 = 0.21; PEFR = 35 Lpm
Initial pressure observed: ___________________________________________
Initial exhaled tidal volume: _________________________________________
High-pressure limit setting: _________________________________________
Low-pressure limit setting: __________________________________________
WYE OCCLUDED
Pressure observed: _______________________________________________
Exhaled tidal volume: ______________________________________________
Alarms activated: _________________________________________________
WYE OPEN (UNOBSTRUCTED)
f = 12; VT = 700 mL; FIO2 = 0.21; PEFR = 35 Lpm
Initial pressure observed: ___________________________________________
Initial exhaled tidal volume: _________________________________________
High-pressure limit setting: __________________________________________
Low-pressure limit setting: __________________________________________
WYE OCCLUDED
2679_Ch41_679-698.indd 687 07/02/13 4:48 PM

E XE RCI SE 4 1 .1 . 3 L O W E X H A LE D V O LU ME A LARMS
Low exhaled tidal volume alarm setting: _______________________________
Low exhaled minute volume setting: __________________________________
WYE OCCLUDED
SIMV 6/SPONTANEOUS RATE 6
Alarms readjustment: ______________________________________________
Low exhaled tidal volume alarm setting: _______________________________
Low exhaled minute volume setting: __________________________________
WYE OCCLUDED
SIMV 6/SPONTANEOUS RATE 6
Alarms readjustment: ______________________________________________
2679_Ch41_679-698.indd 688 07/02/13 4:48 PM

E X E R C IS E 41 . 1. 4 O T H E R V E NTIL ATOR AL ARMS
Alarms Setting
Available Determination Rationale
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Alarms Setting
Available Determination Rationale
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
EXERCISE 41.2 Ventilator Initiation
S C E NA R IO 1
Mode: __________________________________________________________
VT: _____________________________________________________________
f: ______________________________________________________________
Flow or percent inspiratory time: _____________________________________
FIO2: ____________________________________________________________
2679_Ch41_679-698.indd 689 07/02/13 4:48 PM

Patient assessment:
Vital signs: _________________________________________________
Physical assessment of the chest: ______________________________
Auscultation: _______________________________________________
Suctioning: _________________________________________________
Alarm settings: ___________________________________________________
________________________________________________________________
Mode: __________________________________________________________
VT: _____________________________________________________________
f: ______________________________________________________________
FIO2: ____________________________________________________________
Patient assessment:
Vital signs: _________________________________________________
Auscultation: _______________________________________________
Suctioning: _________________________________________________
Alarm settings: ___________________________________________________
________________________________________________________________
SCE N A RI O 2
Mode: __________________________________________________________
VT: _____________________________________________________________
f: ______________________________________________________________
FIO2: ____________________________________________________________
Patient assessment:
Vital signs: _________________________________________________
Auscultation: _______________________________________________
Suctioning: _________________________________________________
Alarm settings: ___________________________________________________
________________________________________________________________
2679_Ch41_679-698.indd 690 07/02/13 4:48 PM

Mode: __________________________________________________________
VT: _____________________________________________________________
f: ______________________________________________________________
FIO2: ____________________________________________________________
Patient assessment:
Vital signs: _________________________________________________
Auscultation: _______________________________________________
Suctioning: _________________________________________________
Alarm settings: ___________________________________________________
________________________________________________________________
S C E N A R IO 3
Mode: __________________________________________________________
VT: _____________________________________________________________
f: ______________________________________________________________
FIO2: ____________________________________________________________
Patient assessment:
Vital signs: _________________________________________________
Auscultation: _______________________________________________
Suctioning: _________________________________________________
Alarm settings: ___________________________________________________
________________________________________________________________
Mode: __________________________________________________________
VT: _____________________________________________________________
f: ______________________________________________________________
FIO2: ____________________________________________________________
2679_Ch41_679-698.indd 691 07/02/13 4:48 PM

Patient assessment:
Vital signs: _________________________________________________
Auscultation: _______________________________________________
Suctioning: _________________________________________________
Alarm settings: ___________________________________________________
________________________________________________________________
SCE N A RI O 4
Mode: __________________________________________________________
VT: _____________________________________________________________
f: ______________________________________________________________
FIO2: ____________________________________________________________
Patient assessment:
Vital signs: _________________________________________________
Auscultation: _______________________________________________
Suctioning: _________________________________________________
Alarm settings: ___________________________________________________
________________________________________________________________
Mode: __________________________________________________________
VT: _____________________________________________________________
f: ______________________________________________________________
FIO2: ____________________________________________________________
Patient assessment:
Vital signs: _________________________________________________
Auscultation: _______________________________________________
Suctioning: _________________________________________________
Alarm settings: ___________________________________________________
________________________________________________________________
2679_Ch41_679-698.indd 692 07/02/13 4:48 PM

EXERCISE 41.3 Circuit Changes
Breaths lost: _____________________________________________________
Time taken: ______________________________________________________
Breath-holding impressions: ________________________________________
________________________________________________________________
Breaths lost: _____________________________________________________
Time taken: ______________________________________________________
Breath-holding impressions: ________________________________________
________________________________________________________________

1. What are the purposes of alarms?
2. How can nuisance alarms be avoided?
3. The physicians in the scenarios want you to justify your initial ventilator settings in scenarios 1, 2, 3, and 4 from
Exercise 41.2. How would you respond? Remember to include your rationale for machine and mode selection.
Scenario 1:
Scenario 2:
Scenario 3:
Scenario 4:
2679_Ch41_679-698.indd 693 07/02/13 4:48 PM

4. What safety precautions should be taken when performing a ventilator circuit change?
5. The physician in each of the scenarios from Exercise 41.2 would like you to recommend the most appropriate humidi-
fication device for the patient. Explain your rationale for each selection.
Scenario 1:
Scenario 2:
Scenario 3:
Scenario 4:
2679_Ch41_679-698.indd 694 07/02/13 4:48 PM


STUDENT: DATE:
ADULT VENTILATOR INITIATION

PERFORMANCE LEVEL
PERFORMANCE RATING
Evaluator: Setting:
Performance Level:
NA = Not applicable
Performance Rating:

2. Connects the ventilator to the appropriate emergency electrical outlets
3. Connects the high-pressure hoses to the appropriate 50-psi gas source outlets
4. Attaches the circuit, filters, and humidification systems as needed
5. Turns on the ventilator and performs any required tests
6. Performs any additional leak tests; corrects and verifies ventilator function

8. Assesses indications for mechanical ventilation; evaluates the patient by performing/observing: vital signs, auscultation, work of breath-
ing, airway patency and placement, pulse oximetry, end tidal CO2, hemodynamic stability, and patient comfort level.
9. Selects the initial ventilator settings according to order or protocol
10. Sets the initial alarm parameters
11. Connects the patient to the ventilator and adjusts the settings and alarms as needed.
12. Analyzes and adjusts FIO2 as indicated
13. Adjusts the circuit humidification system
14. Notes the patient’s LOC, use of sedation, and paralytics
15. Observes and interprets ventilator graphics
16. Completes the patient-system ventilator check
FOLLOW-UP
2679_Ch41_679-698.indd 695 07/02/13 4:48 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
to modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch41_679-698.indd 696 07/02/13 4:48 PM


STUDENT: DATE:
VENTILATOR CIRCUIT CHANGE

PERFORMANCE LEVEL
PERFORMANCE RATING
Evaluator: Setting:
Performance Level:
NA = Not applicable
Performance Rating:


3. Assesses the patient and ventilator system prior to performing the circuit change
4. Ensures that emergency equipment is available
5. Cleans the outside surface of ventilator of dust and debris
6. Changes the filters if needed
7. Has an assistant, if available, manually ventilate the patient
8. Assembles the equipment as completely as possible
9. Places the assembled circuit on the bed with the wye positioned aseptically proximal to the patient
10. Places the other ends proximal to their corresponding connections on the ventilator
11. Silences the alarms
12. Adjusts the FIO2 on the ventilator to hyperoxygenate the patient prior to disconnection (or manually hyperinflates as appropriate)
13. Quickly disconnects the circuit from the patient wye
14. Quickly disconnects the other circuit connections from the ventilator
15. Quickly attaches the ends of the new circuit to the corresponding connections on the ventilator
16. Rapidly assesses the circuit for leaks and ensures ventilator function
17. Reconnects the patient to the ventilator circuit
18. Changes any ancillary equipment as indicated (HME, MDI, or SVN in-line adapter, in-line suction catheter)
19. Observes the pressure and exhaled volume readings; corrects for leaks if needed
20. Verifies alarm function
21. Readjusts the FIO2 and resets the alarms
FOLLOW-UP
2679_Ch41_679-698.indd 697 07/02/13 4:48 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
to modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch41_679-698.indd 698 07/02/13 4:48 PM

CHAPTER Patient-Ventilator
System Care and
Maintenance
INTRODUCTION From the initial application to the discontinuance of mechanical ventilation, respiratory
care practitioners (RCPs) must be able to assess the integrity and effectiveness of the
patient-ventilator system in order to make appropriate modifications to the care plan.
The AARC clinical practice guideline is specific in defining the patient-ventilator system
check. Although this evaluation has been frequently referred as a “vent check,” it is the
documented evaluation of a mechanical ventilator’s function and of the patient’s
response to ventilatory support.1 This routine evaluation must always begin with a
complete assessment of the patient before proceeding to the functional evaluation of the
machine. This assessment should include (but not be limited to) patient responsiveness,
obtaining vital signs, cardiopulmonary auscultation, airway care, evaluation for the
presence of barotrauma or volutrauma, and assessment of patient-ventilator synchrony.
Today’s microprocessor ventilators incorporate the use of graphic waveforms that have
changed the way clinicians assess whether the patient and the ventilator are in
synchrony. Only after careful observation of the patient and interpretation of ventilator
waveforms can synchrony be accomplished.2 Manufacturers have creatively designed
their ventilator screens to produce and display waveforms that monitor airway pressures,
volumes, and flows over real-time. Ventilator waveforms are typically color differentiated
for pressure, volume, and flow. Patient triggering is usually indicated by a corresponding
color change. Waveform configuration and scale is sometimes an optional feature that
can be selected by the clinician. Although the graphic displays are unique to each
ventilator, basic waveform principles apply. Waveforms can assist the clinician in
improving patient-ventilator synchrony and comfort, weaning, and identifying changes
in the patient’s condition.
Once the patient’s response to ventilatory support has been evaluated, proper functioning
of the equipment should be verified. This part of the evaluation should always include a
correlation of the settings with the parameters or protocol ordered by the attending
physician, setting and functioning of alarms, measurement of the inspired gas temperature,
and analysis of the FIO2. As always, if the work is not documented, the work was not done.
Accurate and timely documentation or charting is critical. It is the legal evidence that the
patient-ventilator system check was done in a timely and proper manner.
The goals of mechanical ventilation must be clearly established and continually refined
so that monitoring of the patient-ventilator system leads to the desired outcomes.
699
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OBJECTIVES 1. Apply infection control guidelines and standards associated with equipment and procedures,
Upon completion of this according to OSHA regulations and CDC guidelines.
chapter, you will be able to: 2. Perform patient assessment techniques.
3. Properly verify and document the function of the ventilator.
4. Perform calculations to verify and document the patient’s response to mechanical ventilation.
These calculations specifically include effective dynamic compliance (EDC), effective static
compliance (CST), resistance, and auto-PEEP or intrinsic PEEP.
5. Analyze and interpret waveforms and data generated by the patient-ventilator system.
6. Practice the documentation skills required for a patient-ventilator system check on a ventilator
flow sheet and the skills necessary to generate a narrative or shift note.
7. Practice communication skills needed for the reporting of clinically significant data to the
members of the health-care team.
KEY TERMS
asynchrony loops weaning
dynamic scale x-axis
intrinsic static y-axis
Exercises
F 50-psig regulator manuals
F Adult breathing circuits for ventilators F Microprocessor ventilators with graphic
available display
F Air compressor F Oxygen analyzer and in-line adaptor
F Blender F Respirometer
F Bourdon gauge and Thorpe tube flowmeters F Sterile water
F HEPA bacteria filters F Stethoscope
F High-pressure hoses F T-adapter with small-bore tubing connection
F Home care ventilators and cap
F Hospital bed F Test lungs and lung simulator (if available)
F Humidifiers (heat and moisture exchanger F Watch with second hand
[HME] and heated system) F Water traps
F Intubated or tracheostomized airway F Wrench
management trainer
EXERCISE 42.1 BASIC VENTILATOR MONITORING
These exercises require the initiation of mechanical ventilation for various patient scenarios, as in
Chapter 41, followed by the simulation of a complete patient-ventilator system check and docu-
mentation as on a legal medical document. The ventilator system must be assembled completely
(including gas and electrical sources), and its function must be verified before initiation. Compo-
nents needed for each setup must be selected and obtained by each student. It is recommended
that each scenario be repeated for each available ventilator, and students should completely disas-
semble the ventilator setup after completion of each scenario.
2679_Ch42_699-720.indd 700 08/02/13 4:52 PM

C H A P T E R 42 | PAT I E N T- V E N T I LAT O R S Y S T E M C A R E AND M AINTENANC E • 701
S C EN AR IO 1
1. Set up a volume ventilator with an adult setup and HME.
2. Initiate ventilation. Mr. Lisanti is a 21-year-old, 150-lb man who has just come from the
operating room (OR) after a craniotomy and evacuation of a subdural hematoma. He is
orally intubated, has no documented lung pathology, and is not a smoker. Initiate ventilation
with the following settings: mode = Assist/Control, VT = 500 mL, f = -14/minute, and
Fio2 = 0.35. All other settings and alarms are to be selected by you.
3. Perform a patient-ventilator system check, including patient assessment. Include oxygen
analysis, cuff pressures, and airway care. Record all pertinent data on the ventilator flow
sheet provided in your laboratory report.
4. Write a narrative note documenting your patient’s status and any other data required to
write a comprehensive shift note. Record it on the care progress notes sheet provided in your
laboratory report. This will require you to use your imagination to create clinically relevant
assessment data.
S C EN AR IO 2
1. Set up the ventilator with an adult setup and humidifier.
2. Initiate ventilation. Mrs. Kay is a 30-year-old, 110-lb woman who is in status asthmaticus.
She is in severe acute respiratory acidosis with moderate hypoxemia and has just been nasally
intubated. Initiate ventilation with the following settings: mode = Assist/Control, VT = 500 mL,
f = 12/minute, and Fio2 = 0.50.
write a comprehensive shift note. Record it on your laboratory report. This will require you
to use your imagination to create clinically relevant assessment data.
S C EN AR IO 3
1. Set up the ventilator with an adult setup and humidifier.
2. Initiate ventilation. Miss Aswama is a 38-year-old, 100-lb woman who has myasthenia
gravis. She has been on the ventilator for several weeks with a tracheostomy. Adjust her
settings as follows: mode = SIMV, VT = 450 mL, f = 12/minute, Fio2 = 0.30, pressure
support = 5 cm H2O, and PEEP = 5 cm H2O.
S C EN AR IO 4
1. Set up the ventilator with an adult setup. The type of humidification should be selected
by you.
2. Initiate ventilation. Mr. Lagoudakis is a 60-year-old, 160-lb, 5 ft 6 in. man who is a known
COPD patient with a superimposed respiratory infection, possibly pneumonia. His ABGs are
pH = 7.16, Paco2 = 77 mm Hg, and Pao2 = 49 torr on a 0.40 air-entrainment mask. The
attending physician requests your recommendations for ventilator mode and settings. Initiate
ventilation as you see fit. Orally justify to your laboratory partner the rationale for your
choices, and document the rationale on your laboratory report.
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EXERCISE 42.2 DATA GENERATION FOR EVALUATION OF PATIENT STATUS

EXERCISE 42 .2 .1 EF FEC TIV E DYN AMI C A N D S TAT I C C O MP LI A N C E A N D R E S I S TA N C E
C AL C UL ATION S
1. Using the equipment and settings in the preceding four scenarios, calculate the effective
dynamic compliance (EDC) using the following formula. Record the results on your
laboratory report.
VT / Peak pressure – PEEP
2. Using the same four scenarios, calculate the effective static compliance (CST) using the
following formula. Record the results on your laboratory report.
VT / Plateau pressure – PEEP
Remember that you have to obtain a plateau pressure by instituting an inspiratory pause or
hold. This value is obtained in different ways depending on the brand of ventilator.
Ventilators with external exhalation valves, such as home care ventilators or earlier models,
may require that the exhalation valve tubing be kinked or pinched closed at peak inspiration
to obtain an inspiratory hold until the plateau pressure is achieved. The tubing should then
be released so exhalation can be completed.
3. From the preceding data, calculate resistance by using the following formula. Record the
Peak pressure – Plateau pressure / Flow rate
EXERCISE 4 2 .2 .2 DETER MIN ATION O F A U T O -P E E P

To measure auto-PEEP, an 1. Consult the manufacturer’s manual to determine the method of measuring auto-PEEP or
expiratory hold must be implementing an expiratory hold.
implemented. How this is 2. Set up an adult ventilator on the following settings: mode = Assist/Control, VT = 700 mL,
done depends on the type of f = 24/minute, Fio2 = 0.21, PEEP = 3 cm H2O, and peak flow = 40 Lpm (or percent
ventilator used. inspiratory time = 20%).
3. Attach a test lung to the patient wye.
4. Initiate the expiratory hold or auto-PEEP measurement procedure.
5. Observe the pressure manometer or digital display for the final pressure reading once the
pressure has equilibrated. If auto-PEEP is present, the reading will be above the baseline
PEEP value set. Record the end-expiratory pressure observed on your laboratory report.
6. Calculate auto-PEEP as follows, and record on your laboratory report:
Auto-PEEP = End expiratory pressure – Baseline PEEP pressure
7. Determine which ventilator parameters must be adjusted to eliminate the auto-PEEP. Record
on your laboratory report any recommendations you would make to a physician to change
the ventilator orders.
2679_Ch42_699-720.indd 702 08/02/13 4:52 PM

EXERCISE 42.3 WAVEFORM IDENTIFICATION AND INTERPRETATION

EXER C ISE 42 .3 .1 IDEN TIF I C AT I O N O F P R E S S U R E -T I ME C U R V E S
Figure 42.1 shows a typical
pressure-time curve. The
horizontal x-axis represents
time; the vertical y-axis
represents pressure. Positive
Paw
pressure inspiration is shown
cm H2O Mean airway pressure
as a rise in pressure. The Sec
peak inspiratory pressure
Figure 42.1. Typical pressure-time curve.
appears as the highest point
of the curve. Exhalation is
shown immediately after PIP
and continues until the next
inspiration. The beginning
pressure is referred to as the
baseline, which appears
above zero when PEEP/CPAP Paw
cm H2O
modes are in use. The Sec
Figure 42.2. Patient-initiated mandatory
average mean airway
(PIM) breaths.
pressure is calculated from
the shaded area under the
curve. A negative deflection
immediately before a rise in
pressure indicates the
patient’s effort in patient-
initiated mandatory breaths
Paw
(Fig. 42.2). cm H2O
Small fluctuations in Sec
pressure represent a Figure 42.3. Spontaneous breathing.
patient’s spontaneous
breathing efforts (Fig. 42.3).
Breaths that rise to a plateau
and display varying Plateau
inspiratory times indicate
pressure-supported breaths
(Fig. 42.4). Paw
cm H2O
Breaths that rise to a plateau Sec
and display constant
Figure 42.4. Pressure-supported breaths.
inspiratory time indicate
pressure-controlled breaths
(Fig. 42.5).
In some cases, a ventilator Plateau
may not be able to meet the
required patient inspiratory
demand or the inspiratory Paw
flow may be set too low cm H2O
Sec
(Fig. 42.6).
Figure 42.5. Pressure-control ventilation.
Paw
cm H2O
Sec
Figure 42.6. Inadequate flow rate.
2679_Ch42_699-720.indd 703 08/02/13 4:52 PM

A stable, static plateau
pressure measurement is
needed to accurately
calculate resistance and
compliance (Fig. 42.7). Paw
cm H2O
Sec
Figure 42.7. Static pressure measurements.
EXERCISE 4 2 .3 .2 IDEN TIF ICATION O F FLO W-T I ME C U R V E S

In this type of graphical
representation, expiration is Insp
typically plotted below the
baseline.
Figure 42.8 represents a
Sec
typical flow-time curve in
which inspiration is shown
from A to B and expiration is
Exp
shown from B to C. The peak Figure 42.8. Typical flow-time curve.
inspiratory flow is the
highest flow rate achieved
during inspiration (D). The
Insp
peak expiratory flow rate is Mandatory Spontaneous Pressure support
shown as E.
Figure 42.9 illustrates
various breath types. Sec
Figure 42.10 shows a flow-
time curve indicating auto- Figure 42.9. Flow-time curves indicating
PEEP. Note that the breath types. Exp
expiratory flow does not
return to baseline before the
next breath is initiated.
Figure 42.11 shows
inspiratory flow patterns that
can be selected for
mandatory, volume-based
breaths on most ventilators. Figure 42.10. Flow-time curves
indicating auto-PEEP.
Insp
Square Decelerating Sine
Sec
Figure 42.11. Flow patterns. Exp
2679_Ch42_699-720.indd 704 08/02/13 4:52 PM

EXER C ISE 42 .3 .3 IDEN TIF I C AT I O N O F V O LU ME -T I ME C U R V E S

Figure 42.12 shows a typical
volume-time curve in which
the upslope indicates
inspiratory volume and the
downslope indicates VT
Liters
expiratory volume. Sec
Inspiratory time is measured
from the beginning of Figure 42.12. Typical volume-time curve.
inspiration to the beginning
of expiration. Expiratory time
is measured from the
beginning of exhalation to
the beginning of the
VT
subsequent inspiration. In Liters
this figure, the patient has Figure 42.13. Detecting air trapping Sec
exhaled fully before the next or leaks.
breath. An increase in
respiratory rate would be
acceptable and would not
cause air trapping.
Figure 42.13 indicates an
exhalation that does not
return to zero. Volume in and
volume out are not always
equal.
EXER C ISE 42 .3 .4 P R ESSU R E -V O LU ME LO O P

Figure 42.14 shows a typical Liters
pressure-volume loop for a Baseline = 0 cm H2O
mandatory breath. Pressure Relative pressure range = 60 cm H2O
Inspiratory area = 0.028
is plotted on the horizontal
axis and volume on the
vertical axis. The lower
segment of the curve
represents inspiration, the
upper portion expiration.
Inspiration is plotted first Paw
Figure 42.14. Typical pressure-volume loop cm H2O
and the loop moves for a mandatory breath.
counterclockwise.
Figure 42.15 shows a
VT
pressure-triggered Liters
spontaneous breath with Baseline = 0 cm H2O
inspiration indicated by Relative pressure range = 60 cm H2O
A and exhalation indicated Inspiratory area = 0.116
by B. The entire inspiratory

area appears to the left of
the y-axis and is plotted first
so the entire loop moves
clockwise.
Paw
Figure 42.15. Pressure-volume loop for cm H2O
a spontaneous breath.
2679_Ch42_699-720.indd 705 08/02/13 4:52 PM

Figure 42.16 shows a
VT
pressure-volume loop for an Liters
assisted breath. The patient Baseline = 0 cm H2O
initiates the breath and Relative pressure range = 60 cm H2O
inspiration begins plotting
clockwise to the left of the
y-axis, but when the ventilator
takes over, the plot direction
shifts to counterclockwise to
the right of the y-axis.
Paw
Figure 42.16. Pressure-volume cm H2O
loop for an assisted breath.
EXERCISE 4 2 .3 .5 IN TERPRETATION O F WAV E FO R MS

For Figures 42.17 through 42.23, identify the data indicated and record your interpretations on
the laboratory report.
1. Figure 42.17:
A. Mode of ventilation
B. Inspiratory time for the first curve
C. Line A–B
D. What is occurring at point C?
E. Suggested correction for point C
2. Figure 42.18:
B. Explain the difference between curves A and B. What adjustment was made to correct
curve A?
3. Figure 42.19:
A. Explain the difference in A for curves 1 and 2.
B. What possible treatment interventions would have caused this change?
4. Figure 42.20:
B. Respiratory rate
C. Events at points A and B
5. Figure 42.21:
B. Respiratory rate
C. Events at points A and B
6. Figures 42.22 and 42.23:
A. Which curve illustrates the greater work of breathing?
B. What modalities could be implemented to result in the change from curve VI to curve VII?
Paw
cm H2O
Sec
Figure 42.17. Evaluating respiratory events I.
Paw
cm H2O
Sec
Figure 42.18. Evaluating respiratory events II.
2679_Ch42_699-720.indd 706 08/02/13 4:52 PM

Before After
Insp
Sec
Exp
Figure 42.19. Evaluating respiratory events III.
Paw
cm H2O
Sec
VT
Liters
Sec
Figure 42.20. Evaluating respiratory events IV.
Paw
cm H2O
Sec
VT
Liters
Sec
Figure 42.21. Evaluating respiratory events V.
Liters
Baseline = 0 cm H2O
Relative pressure range = 60 cm H2O
Paw
cm H2O
Figure 42.22. Evaluating respiratory events VI.
2679_Ch42_699-720.indd 707 08/02/13 4:52 PM

VT
Liters
Baseline = 0 cm H2O
Relative pressure range = 60 cm H2O
Paw
cm H2O
Figure 42.23. Evaluating respiratory events VII.
EXERCISE 42.4 SETTING MODIFICATION AND DOCUMENTATION
The following scenarios are continuations from the scenarios introduced in Exercise 42.1.
SCENARIO 1
Mr. Lisanti is a 21-year-old, 150-lb man who has just come from the OR after a craniotomy and
evacuation of a subdural hematoma. He is orally intubated, has no documented lung pathology,
and is not a smoker. Ventilation was initiated with the following settings: mode = Assist/Control,
VT = 500 mL, f = 14/minute, and Fio2 = 0.35. An arterial blood gas was drawn 30 minutes
later with the following results: pH = 7.29, Paco2 = 45 mm Hg, Hco3 = 21, and Pao2 = 110.
The physician has requested that you adjust the ventilator to hyperventilate the patient for the
first 24 hours to maintain a Paco2 between 25 to 30 mm Hg and maintain the Pao2 at 80 to
90 mm Hg.
1. Formulate the clinical data required to make recommendations for changes in the ventilator
settings and record them on your laboratory report. Use any formulas or rules of thumb (see
the Appendix) that are applicable to the situation.
2. With your lab partner acting as the physician, present your rationale orally.
3. The physician agrees with your recommendations. Implement the changes and record them
The next day, the patient has regained consciousness. You have measured bedside weaning
parameters and have decided that the patient is ready to be weaned
1. Identify what the minimal acceptable values would be for VC, MIP, MVV, and VT in this
“patient” and record them on your laboratory report.
2. State what method of weaning you would recommend and record your answer and rationale
SCENARIO 2
Mrs. Kay is a 30-year-old, 110-lb woman who is in status asthmaticus. She is in severe acute re-
spiratory acidosis with moderate hypoxemia and has just been nasally intubated. Ventilation was
initiated with the following settings: mode = Assist/Control, VT = 500 mL, f = 12/minute, and
Fio2 = 0.50. Before taking the initial blood gas on the ventilator, you observe that the high-
pressure alarm is continually sounding with each breath and only 380 mL of exhaled volume
is measured. Auscultation reveals markedly diminished breath sounds bilaterally.
1. Identify the two most likely causes of this situation and make recommendations to correct
these problems. Record your answers on your laboratory report.
Two days later, Mrs. Kay is stable and ready to be weaned. She is currently on SIMV 8/
minute, VT 400 mL, and Fio2 = 40%. Total breath rate is 28 breaths/minute and
spontaneous VT = 200 to 250 mL. Blood gases reveal pH = 7.48, Paco2 = 32 mm Hg,
Hco3 = 25, and Pao2 = 135 mm Hg.
2. What changes would you recommend to commence weaning at this time? Record your
suggestions and rationale on your laboratory report.
2679_Ch42_699-720.indd 708 08/02/13 4:52 PM

S C EN AR IO 3
Miss Aswama is a 38-year-old, 100-lb woman who has myasthenia gravis. She has been on the
ventilator for several weeks with a tracheostomy: mode = SIMV, VT = 450 mL, f = 12/minute,
Fio2 = 0.30, pressure support = 5 cm H2O, and PEEP = 5 cm H2O. The capnometry reading has
been stable at 38 mm Hg and Spo2 = 94%, VC = 800 mL, and MIP = –30 cm H2O. Weaning has
begun on pressure support of 10 cm H2O, CPAP = 3, and Fio2 = 0.30. One hour later, the cap-
nometry reading is 45 mm Hg and Spo2 = 88%.
1. What changes in vital signs and symptoms would you expect based on these values? What
recommended changes would you make at this time? Record your answers and rationale on
R E FE R E N C E S
1. AARC Clinical Practice Guideline. Patient-ventilator system checks. Respir Care 37(8):882–886, 1992.
2. deWit, M. Monitoring of patient-ventilator interaction at the bedside. Respir Care 56(1):61 – 68, 2011.
2679_Ch42_699-720.indd 709 08/02/13 4:52 PM

2679_Ch42_699-720.indd 710 08/02/13 4:52 PM
Laboratory Report
CHAPTER 42: PATIENT-VENTILATOR SYSTEM CARE AND MAINTENANCE
Name: Date:
Data Collection
EXERCISE 42.1 Basic Ventilator Monitoring
For each scenario, use the patient-ventilator system check flow sheet and progress note forms to document your settings.
SCENARIO 1
Mode = Assist/Control, VT = 500 mL, f = 14/minute, FIO2 = 0.35
SCENARIO 2
Mode = Assist/Control, VT = 500 mL, f = 12/minute, FIO2 = 0.50
SCENARIO 3
Mode = SIMV, VT = 450 mL, f = 12/minute, FIO2 = 0.30, pressure support = 5 cm H2O, PEEP = 5 cm H2O
SCENARIO 4
Rationale: ___________________________________________________________________________________________________
____________________________________________________________________________________________________________
EXERCISE 42.2 Data Generation for Evaluation of Patient Status
E X E R C IS E 42 . 2. 1 E FF E C T IV E DYN AMIC AN D STATIC COMPL IAN CE AN D RESISTAN CE CALCULATI ONS
Show your work.
SCENARIO 1
EDC = ______________________________________________________________________
CST = _______________________________________________________________________
RAW = ______________________________________________________________________
SCENARIO 2
EDC = ______________________________________________________________________
CST = _______________________________________________________________________
RAW = ______________________________________________________________________
SCENARIO 3
EDC = ______________________________________________________________________
CST = _______________________________________________________________________
RAW = ______________________________________________________________________
2679_Ch42_699-720.indd 711 08/02/13 4:52 PM

SCENARIO 4
EDC = ______________________________________________________________________
CST = _______________________________________________________________________
RAW = ______________________________________________________________________
E XE RCI SE 4 2 .2. 2 D E T E R M INAT IO N O F A U T O-PEEP
End-expiratory pressure = ______________________________________________________
Calculated auto-PEEP (show your work) = _________________________________________
Recommendations and adjustments: ______________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
EXERCISE 42.3 Waveform Identification and Interpretation
E XE RCI SE 4 2 .3 . 5 IN T E R P R E TAT IO N O F WAV EF ORMS
Figure 42.17
Mode of ventilation = __________________________________________________________
Inspiratory time for the first curve = ______________________________________________
Line A–B = __________________________________________________________________
What is occurring at point C? ___________________________________________________________________________________
____________________________________________________________________________________________________________
Suggested correction for point C: ________________________________________________________________________________
____________________________________________________________________________________________________________
Figure 42.18
Explain the difference between curves A and B. What adjustment was made to correct curve A? ______________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Figure 42.19
Explain the difference in A for curves 1 and 2: ______________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
What possible treatment interventions would have caused this change? _________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
2679_Ch42_699-720.indd 712 08/02/13 4:52 PM

Figure 42.20
Respiratory rate = ____________________________________________________________
Event at point A = _____________________________________________________________
Event at point B = _____________________________________________________________
Figure 42.21
Respiratory rate = _____________________________________________________________
Events at points A and B = ______________________________________________________________________________________
____________________________________________________________________________________________________________
Figures 42.22 and 42.23
Which curve illustrates the greater work of breathing? _______________________________________________________________
What modalities could be implemented to result in a change from curve VI and curve VII? ___________________________________
____________________________________________________________________________________________________________
EXERCISE 42.4 Setting Modification and Documentation
SCENARIO 1
Clinical data required: _________________________________________________________________________________________
____________________________________________________________________________________________________________
Formulas, rules of thumb used: __________________________________________________________________________________
____________________________________________________________________________________________________________
Changes implemented: _________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Minimal acceptable values:
VC _________________________________________________________________________
MIP ________________________________________________________________________
MVV _______________________________________________________________________
VT ________________________________________________________________________________________________________________
Method of weaning recommended and rationale: ____________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
2679_Ch42_699-720.indd 713 08/02/13 4:52 PM

SCENARIO 2
Identify the two most likely causes: _______________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Recommendation to correct these problems: _______________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
What changes would you recommend 2 days later? __________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
SCENARIO 3
What changes in vital signs and symptoms would you expect based on these values? What recommended changes would you make at
this time? ___________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

1. You are at the bedside of a patient receiving mechanical ventilation and the nurse asks you what information you can
gather about the patient’s mechanical ventilation support by observing the waveforms.
2. Using the available mechanical ventilators in your lab exercise, explain how you would determine whether a ventilator
breath is patient or machine triggered.
2679_Ch42_699-720.indd 714 08/02/13 4:52 PM

3. You are completing a patient-ventilator system check for a postoperative patient who underwent an abdominal aortic
aneurysm. The patient is currently on the following settings:
Assist/Control f = 14 Vt = 400 mL Fio2 = 60%
PEEP = 5 cm H2O
The surgical resident would like to know how you can use waveforms to identify if any of the following conditions
were to occur:
A. Bronchospasm
B. Retention of airway secretions
C. Pneumothorax
2679_Ch42_699-720.indd 715 08/02/13 4:52 PM

PATIENT-VENTILATOR SYSTEM CHECK

PT ID:
DATE
TIME
MODE
SET RATE
TOTAL RATE
SET VT/VE
EXH. VT/VE
SPONT. VT
SET FIO2
ANALYZED FIO2
PSV
PEEP/CPAP
FLOW/%I-TIME
FLOW PATTERN
I:E RATIO
SENSITIVITY
PIP
PLATEAU
MAP
HME/GAS TEMP
HIGH P
LOW P
LOW VT/VE
HI/LOW O2
LOW PEEP/CPAP
TEMP ALARM
AUTO-PEEP
EDC
CST
RAW
TUBE SIZE/TYPE
TUBE PLACEMENT
CUFF PRESS
SpO2
PECO2
BP
HR
ECG
TEMP
pH
PaCO2
COHB/METHB
C.O.
PAP
PWP
2679_Ch42_699-720.indd 716 08/02/13 4:52 PM


PT ID:
PVO2
SVO2
CaVO2
SIGNATURE
DATE TIME RESPIRATORY CARE PROGRESS NOTES
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2679_Ch42_699-720.indd 718 08/02/13 4:52 PM


STUDENT: DATE:
ADULT PATIENT-VENTILATOR SYSTEM CARE

PERFORMANCE LEVEL
PERFORMANCE RATING
Evaluator: Setting:
Performance Level:
NA = Not applicable
Performance Rating:


3. Assesses the patient by performing/observing:
A. Vital signs
B. Physical examination of the chest
C. Auscultation
D. Airway placement and patency
E. Pulse oximetry
F. EtCO2
G. Hemodynamic stability parameters
H. Subjective comfort level
4. Assesses cuff inflation and adjusts if necessary
5. Performs humidifier maintenance
6. Analyzes FIO2
7. Verifies all ventilator settings and adjusts if necessary
8. Verifies all alarm settings and adjusts if necessary
9. Assesses for weaning potential
10. Measures spontaneous respiratory rate and volume, if indicated
11. Calculates EDC, Cst, and Raw
12. Measures auto-PEEP and adjusts if necessary
13. Analyzes and interprets waveforms and adjusts the ventilator if necessary
FOLLOW-UP
2679_Ch42_699-720.indd 719 08/02/13 4:52 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch42_699-720.indd 720 08/02/13 4:52 PM

CHAPTER Discontinuation
of Mechanical
Ventilation
INTRODUCTION The initiation of invasive mechanical ventilation is an important decision. After

ventilator initiation, the adequacy of the ventilatory strategies is constantly being
assessed by the members of the health-care team. However, prolonged invasive
mechanical ventilation has serious complications and is extremely costly.1 Therefore,
once the patient’s clinical condition has stabilized, the patient-ventilator care plan
must be revised to develop a successful strategy for the discontinuation of mechanical
ventilation. Often termed weaning, the process begins with the assessment of weaning
readiness because it is important that the discontinuation effort not be premature.2
The tolerance of a spontaneous breathing test (SBT), coupled with other pertinent
data, will help determine weaning readiness and the best method for weaning. These
strategies include the complete removal of mechanical ventilation, allowing the patient
to breathe spontaneously, or the gradual removal of ventilatory support. The use of
weaning protocols helps to structure the weaning process and has been shown to
improve patient outcomes.2,3 In addition to therapist-directed partial support and
spontaneous modes that are typically used for weaning, newer ventilators now offer a
computer-directed weaning feature. This feature is capable of auto-adjusting ventilator
settings to accommodate a patient’s ability to assume his or her own work of breathing
and thus auto-weans the patient from mechanical support.
Respiratory care practitioners (RCPs) play a key role in the assessment of weaning
readiness and in the implementation of weaning protocols and computer-directed
weaning to achieve weaning success. Unfortunately, not every weaning attempt is
successful. Ventilator dependence due to a failure to wean may result in the patient
being transferred to a long-term acute-care hospital (LTACH) or subacute care setting.
In these settings, the weaning strategy includes building respiratory strength and
endurance through lengthening the duration of SBTs. By liberating the patient from
mechanical ventilation for extended periods of time during the day, the patient is better
able to participate in physical therapy and weaning success is more likely.5
OBJECTIVES 1. Identify the various weaning modalities found on commercially available ventilators.
Upon completion of this 2. Discuss the clinical considerations, including contraindications, for determining weaning
chapter, you will be able to: readiness.
3. Evaluate the objective measurements required for determining weaning readiness.
4. Evaluate and implement a weaning protocol.
5. Identify the various computer-directed weaning options available on current critical care
ventilators.
KEY TERMS
computer-directed weaning spontaneous breathing test (SBT) ventilator dependence
721
2679_Ch43_721-732.indd 721 07/02/13 4:48 PM

Exercises
F 50-psi oxygen source F Negative inspiratory force (NIF) meter/
F 50-psig regulator manometer
F Air compressor F Sterile water
F Blender F T-adapter with small-bore tubing connection
F Bourdon gauge and Thorpe tube flowmeters and cap
F Critical care ventilators F Test lungs and lung simulator (if available)
F HEPA bacteria filters F Watch with a second hand
F High-pressure hoses F Water traps
F Humidifiers (heat and moisture exchanger F Wrench
[HME] and heated humidifier system)
F Manufacturer’s operation and maintenance
manuals (videos if available)
EXERCISE 43.1 WEANING MODALITIES
1. Review Table 40.1.

2. Review or repeat, if instructed, Exercises 40.3, 40.5.1, 40.5.2, and 40.5.3.
3. Identify the modes used for weaning. Record the modes on your laboratory report.
4. Identify the modes that can be used in combination during weaning. Record the modes on
EXERCISE 43.2 ASSESSMENT DURING WEANING
Using your textbooks and other resources, complete Table 43.1 of weaning parameters. Record
the completed table on your laboratory report.
Table 43.1 Patient Assessment

Parameter Minimally Acceptable Value for Weaning
Weaning Parameters
pH
PaCO2
PaO2
FIO2
PEEP
PaO2/FIO2
Systolic BP
Heart rate
Hgb
Chest x-ray
CVP
Pulmonary wedge pressure
Urinary output
Vital capacity
Minute ventilation
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C H A P T E R 43 | D I S C O N T I N U AT I O N O F M E C H ANIC AL V ENTILATION • 723
Table 43.1 Patient Assessment
Weaning Parameters (continued)
Negative inspiratory force (NIF)
Maximum inspiratory pressure (MIP)
Rapid shallow breathing index (RSBI)
Patient responsiveness
Sedation
EXERCISE 43.3 WEANING PROTOCOLS
Your instructor will provide you with various weaning protocols from clinical sites, the AARC
website, or other sources. Read the protocols and record the answers to the following questions
1. What is the first step in each protocol?
2. List at least three contraindications to weaning.
3. What parameters are measured in the protocols?
4. How do the values compare to the values recorded in Exercise 43.2?
5. If the criteria for weaning are met, is the patient given a spontaneous breathing trial?
6. What measurements are made to document patient tolerance?
7. What is the procedure if the patient does not tolerate the weaning effort?
8. At what point is the physician notified of the patient’s status?
EXERCISE 43.4 COMPUTER-DIRECTED WEANING OPTIONS
1. Using the ventilators available in your laboratory, identify the available computer-directed
weaning options on each. Review the manual to become familiar with how the ventilator is
designed to adjust for automatic weaning. Record your answers on your laboratory report.
2. Research the literature for current ventilators offering an automatic weaning option.
Compare each to determine how the ventilator is designed to automatically adjust to wean
the patient from mechanical support. Record your findings on your laboratory report.
R E FE R E N C E S
1. Marelich, GP, et al: Protocol weaning of mechanical ventilation in medical and surgical patients by respiratory care practitioners and
nurses. Chest 118:459–467, 2000.
2. McIntyre, NR, et al: Evidence-based guidelines for weaning and discontinuing ventilator support. Chest 120(6):375–395, 2001.
3. Marx, WH, et al: Cost reduction and outcome improvement in the intensive care unit. J Trauma 46:625–629, 1999.
4. MacIntyre, NR: Evidence-based ventilator weaning and discontinuation. Respir Care 49(7): 830–836, 2004.
5. Ghamloush, M, O’Connor, H, and White, A: Patient-ventilator interaction in the LTAC hospital. Respir Care 56(2):207-213, 2011.
2679_Ch43_721-732.indd 723 07/02/13 4:48 PM

2679_Ch43_721-732.indd 724 07/02/13 4:48 PM
Laboratory Report
CHAPTER 43: DISCONTINUATION OF MECHANICAL VENTILATION
Name: Date:
Data Collection
EXERCISE 43.1 Weaning Modalities
Modes used for weaning: ________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Modes used in combination: ______________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
2679_Ch43_721-732.indd 725 07/02/13 4:48 PM

EXERCISE 43.2 Assessment During Weaning

pH
PaCO2
PaO2
FIO2
PEEP
PaO2/FIO2
Systolic BP
Heart rate
Hgb
Chest x-ray
CVP
Pulmonary wedge pressure
Urinary output
Vital capacity
Minute ventilation
Negative inspiratory force (NIF)
Maximum inspiratory pressure (MIP)
Rapid shallow breathing index (RSBI)
Patient responsiveness
Sedation
EXERCISE 43.3 Weaning Protocols
What is the first step in each protocol?
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
List at least three contraindications to weaning:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
2679_Ch43_721-732.indd 726 07/02/13 4:48 PM

What parameters are measured in the protocols?
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
How do the values compare to the values recorded in Exercise 43.2?
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
If the criteria for weaning are met, is the patient given a spontaneous breathing trial?
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
What measurements are made to document patient tolerance?
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
What is the procedure if the patient does not tolerate the weaning effort?
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
2679_Ch43_721-732.indd 727 07/02/13 4:48 PM

At what point is the physician notified of the patient’s status?
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
EXERCISE 43.4 Computer-Directed Weaning Options
VENTILATOR 1. Name and model: __________________________________________________________________________________
Name of computer-directed weaning feature: ________________________________________________________________________
Describe how the ventilator adjusts to provide auto-weaning: ___________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
VENTILATOR 2. Name and model: __________________________________________________________________________________
Name of computer-directed weaning feature: ________________________________________________________________________
Describe how the ventilator adjusts to provide auto-weaning: ____________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________

1. Can there be a psychological component to ventilator dependence? If so, what factors contribute to the dependence?
2. After several failed attempts at weaning, Mr. Smokes, a 65-year-old male with COPD, has been transferred to a
ventilator-dependent care unit. What are some of the factors that might have contributed to the weaning failure?
Include both subjective and objective assessments in your answer.
2679_Ch43_721-732.indd 728 07/02/13 4:48 PM

3. Based on the protocols used in Exercise 43.3, can you suggest any changes or additions that might improve the
effectiveness of the protocol?
4. What are the advantages and disadvantages of replacing traditional weaning strategies with ventilators capable of
computer-directed weaning?
2679_Ch43_721-732.indd 729 07/02/13 4:48 PM

2679_Ch43_721-732.indd 730 07/02/13 4:48 PM

STUDENT: DATE:
VENTILATOR WEANING PROTOCOLS
PERFORMANCE LEVEL
PERFORMANCE RATING
Performance Level:
NA = Not applicable
Performance Rating:


3. Assesses the patient for weaning readiness including documentation
4. Checks the chart for:
A. Recent chest x-ray
B. Recent ABG
C. Laboratory results of CBC and hematology
D. Adequate urinary output
E. Discontinuance of sedation
5. Assesses the following parameters:
A. Hemodynamic stability
B. Vital signs
C. Vital capacity, negative inspiratory force (NIF), or maximal inspiratory pressure (MIP)
6. Selects the proper mode for weaning
7. Adjusts the ventilator to proper modes and settings
8. Explains the procedure to the patient if applicable
9. Implements the weaning protocol based on facility policy
10. Monitors the patient’s tolerance of the weaning procedure:
A. Adequacy of oxygenation
B. Adequacy of ventilation
C. Hemodynamic stability
11. Assesses the patient’s subjective tolerance
12. Readjusts the ventilator settings as indicated by protocol
13. Discontinues the weaning if not tolerated and notifies the RN and MD
FOLLOW-UP
2679_Ch43_721-732.indd 731 07/02/13 4:48 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch43_721-732.indd 732 07/02/13 4:48 PM

CHAPTER Neonatal/Pediatric
Respiratory Care
INTRODUCTION The respiratory system is very frequently the primary target in many infant and pediatric
diseases. Therapeutic and technological advances in medicine have dramatically
improved the survival of newborns. The high incidence of pediatric asthma and long-
term survival of children with genetic disorders such as cystic fibrosis have contributed
to the significant demand for perinatal/pediatric respiratory care specialists.
Because a family-centered approach to patient care is essential to cope with the

additional psychological and emotional stress encountered when a child is sick,1 the
respiratory care practitioner (RCP) must learn how to interact and communicate with
families in these difficult times.
Although basic concepts of quality patient care are similar in adults and children, the
indications, goals, and hazards associated with respiratory care must be modified to
meet the special needs of this patient population. Techniques, procedures, equipment,
and expected outcomes are often significantly altered from the adult population.2,3
OBJECTIVES 1. Practice communication skills needed for the instruction of patients and family members in
Upon completion of this respiratory care of neonatal and pediatric patients.
chapter, you will be able to: 2. Apply patient assessment techniques to a neonatal or pediatric patient.
3. Modify respiratory care procedures to meet the special needs of the neonatal or pediatric
patient.
5. Demonstrate the required steps to resuscitate a newborn according to the current neonatal
resuscitation program guidelines.
6. Select, assemble, verify, and document the function of a neonatal CPAP.
KEY TERMS
abruptio placentae ductus arteriosus lecithin/sphingomyelin polyhydramnios
acrocyanosis ductus venosus (L/S) ratio postterm
amniotic fluid dystocia meconium preeclampsia
anomaly eclampsia Moro reflex preterm
Apgar score fetal asphyxia neonate tocolytic
breech foramen ovale oligohydramnios umbilical artery
cesarean gestation para umbilical vein
choanal atresia gravida periodic breathing vernix
chorionic villi hyperbilirubinemia placenta
diaphragmatic hernia lanugo placenta previa
733
2679_Ch44_733-748.indd 733 07/02/13 4:48 PM

Exercises
F 50-psi oxygen source F Neonatal and pediatric sizes of the following:
F 50-psig regulator F Aerosol masks
F Air compressor F Nasal cannula
F Blender F Oxygen masks
F Blood pressure cuffs F Spacers with masks
F Bourdon gauge and Thorpe tube flowmeters F Oxygen analyzers
F Bulb syringe F Pediatric care doll or mannequin
F Cloth tape F Percussion cups
F Endotracheal tube connector F Respiratory transfer set (continuous feed
F Endotracheal tubes system)
F HEPA bacteria filters F Respirometer
F High-pressure hoses F Small-volume nebulizers
F Humidifiers F Sterile water
F Infant airway management trainer F Stethoscopes
F Infant mannequin F Suction catheters
F Infant nasal CPAP setup F T-adapter with small-bore tubing connection
F Infant self-inflating and flow-inflating manual and cap
resuscitators with masks F Temperature probes
F T-piece resuscitator F Ventilator circuits (heated-wire circuits if
F Infant ventilator circuits available)
F Large-volume nebulizers F Watch with second hand
F Manufacturers’ operation and maintenance F Water traps
manuals (videos if available) F Wrenches
F Miller laryngoscope blades and handles
EXERCISE 44.1 PATIENT ASSESSMENT IN THE NEWBORN

EXERCISE 44.1.1 MATER N AL ASSES S ME N T
For this exercise you, or 1. Introduce yourself and your department to the mother.
your group, will need to 2. Explain the purpose of the interview.
get permission from a 3. Interview the mother and take a history with special emphasis on the following:
pregnant woman or any F Date of birth
woman who has given birth F Date of last menses
to perform a “prenatal” F Number of pregnancies (gravida) and number carried to term (para)
history and interview. F Multiple gestations
F Any medications taken during pregnancy
F History of diabetes, hypertension, toxemia, preeclampsia, maternal hypertension,
eclampsia, previous fetal loss, smoking, pulmonary disease, previous breech births,
rH factors, oligohydramnios, polyhydramnios, previous meconium stains, previous
placental problems, maternal sepsis, in utero infections, cardiac disease, drug use,
alcohol use, sexually transmitted diseases
4. Chart the history on your laboratory report.
2679_Ch44_733-748.indd 734 07/02/13 4:48 PM

C H A P T E R 44 | N E O N ATA L/ P E D I AT R I C R ES P IR ATORY C AR E • 735
EXER C ISE 44 .1 .2 P R EPAR AT I O N FO R R E S U S C I TAT I O N O F T H E N E W B O R N

Prepare a cart or table with Radiant warmer
all the listed equipment and Suction equipment
supplies you will need for Bulb syringe
resuscitation of the neonate Vacuum
before performing the Suction catheter
following exercises. DeLee trap
Ventilation equipment
Resuscitation bag
Masks
Pressure manometer
Oxygen tubing
T-piece resuscitator
Oxygen source
Laryngoscope
Handles
Batteries
Blades
Endotracheal tubes (sizes 2.5 to 4 mm)
Nasogastric tubes
Umbilical vessel catheter equipment
Syringes
Blood gas analysis equipment
EXER C ISE 44 .1 .3 IDEN TIF I C AT I O N O F T H E C O MP O N E N T S O F A T-P I E C E R E S U S C I TAT O R

Use the following list to identify the labeled parts of the T-piece resuscitator in Figure 44.1, and
Maximum pressure relief (not shown)
Circuit pressure
Gas inlet
Inspiratory pressure control
Gas outlet
PEEP adjustment
D B
E A
Figure 44.1. T-piece resuscitator setup.
2679_Ch44_733-748.indd 735 07/02/13 4:48 PM

EXERCISE 4 4 .1 .4 R ESUS C ITATION O F T H E N E W B O R N

In the following scenarios, you will initiate basic life support. It is expected that you will
have already had instruction in basic life support for health-care providers before this labora-
tory. Refer to current American Heart Association (AHA)4 or American Red Cross (ARC)
cardiopulmonary resuscitation (CPR) guidelines for specific details. You will also perform
Apgar scoring. Table 44.1 shows the Apgar scoring system.
Using the algorithm shown in Figure 44.2, simulate on an infant mannequin what would need
to be done in the following scenarios.
Table 44.1 Apgar Scoring System

0 1 2
Heart Rate None <100 >100
Respiratory Rate None Weak, irregular Strong cry
Color Pale blue Acrocyanosis Pink
Reflex Irritability No response Grimace Cry, cough, or
sneeze
Muscle Tone Limp Some flexion Well-flexed
Term gestation?
Breathing or crying?
Clear amniotic fluid?
Good muscle tone?
No
Provide warmth
Clear airway if necessary
Dry
Stimulate
Evaluate: Respiration,
HR, color
Labored breathing,
Apneic or HR < 100?
or persistent cyanosis
Yes
Give supplementary O2
with PPV Clear airway, SpO2
monitoring, consider
CPAP
HR < 60?
Yes
Give O2 with PPV

Give chest compressions
Consider intubation
Figure 44.2. Overview of resuscitation in the delivery room.

HR indicates heart rate (shown in bpm). Endotracheal
intubation may be considered at several steps. (Adapted from HR < 60? Intubate if no chest rise
Kattwinkel J, et al: Part 15: Neonatal resuscitation: 2010
American Heart Association guidelines for cardiopulmonary Yes
resuscitation and emergency cardiovascular care. Circulation
122(suppl 3): S909–S919, 2010. © 2010 American Heart Administer epinephrine
Association, Inc.)
2679_Ch44_733-748.indd 736 07/02/13 4:48 PM

Scenario 1: Baby Boy Marcos
You are present for the The following is noted in the initial assessment of Baby Boy Marcos:
delivery of a 42-week- Weight 8.0 lb
gestation neonate. The Central cyanosis
mother has been in labor Grimaces noted when bulb suction of nares performed
for 30 hours and has Heart rate 90
evidence of meconium Respiratory rate 40 with periods of apnea, retractions noted
staining in the amniotic Extremities some flexion
fluid. 1. Perform an Apgar score for this scenario, and record the score on your laboratory report.
2. Referring to the resuscitation algorithm, perform the required resuscitation procedures.
3. “Chart” the event on your laboratory report.
Scenario 2: Baby Girl A and Baby Girl B Williams
You have been called The following is noted in the initial assessment of Baby Girl A:
to the delivery room in Weight 3.5 lb
anticipation of the delivery Complete cyanosis
of 30-week-gestation twins. No grimaces noted when bulb suction of nares performed
Heart rate 60
Respiratory rate none
Limp
The following is noted in the initial assessment of Baby Girl B:
Weight 4.0 lb
Acrocyanosis
Crying and sneeze stimulated with bulb suction of nares
Heart rate 130
Respiratory rate 60 and irregular
Well-flexed
1. Perform an Apgar score for each twin and record the scores on your laboratory report.
2. Referring to the resuscitation algorithm, perform the required resuscitation procedures for
each twin.
3. Chart the events on your laboratory report.
EXERCISE 44.2 NASAL CONTINUOUS POSITIVE AIRWAY PRESSURE FOR THE INFANT3
1. For Baby Boy Marcos in Scenario 1, Exercise 44.1.4: After a successful resuscitation, the
baby is placed on nasal CPAP of 5 cm H2O and an Fio2 of 0.80. Set up the equipment
needed as shown in Figure 44.3.
Figure 44.3. Infant nasal continuous positive airway

pressure (CPAP) setup.
2679_Ch44_733-748.indd 737 07/02/13 4:48 PM

2. Initiate CPAP using a mannequin. “Chart” the procedure, documenting your “patient”
assessment and any other data required to write a comprehensive note, and record it on your
laboratory report. This will require you to use your imagination to create clinically relevant
assessment data. Include expected capillary blood gases and noninvasive monitoring results.
RE F E RE N CE S
1. Walsh, BK, Czervinske, MP, and DiBlasi, RM: Perinatal and Pediatric Respiratory Care, ed. 3. WB Saunders, Philadelphia, 2009.
2. American Association for Respiratory Care: AARC clinical practice guideline: Selection of an oxygen delivery device for neonatal and
pediatric patients. Revision and Update. Respir Care 4(47):707–716, 2002.
3. American Association for Respiratory Care: AARC clinical practice guideline: Application of continuous positive pressure to neonates via
nasal prongs, nasopharyngeal tube, or nasal mask. Revision and Update. Respir Care 49(9):1100–1108, 2004.
4. American Heart Association: Highlights of the 2010 American Heart Association Guidelines for CPR and ECC. http://guidelines.ecc.org/
index.html. Accessed March 28, 2012.
2679_Ch44_733-748.indd 738 07/02/13 4:48 PM

Laboratory Report
CHAPTER 44: NEONATAL/PEDIATRIC RESPIRATORY CARE
Name: Date:
Data Collection
EXERCISE 44.1 Patient Assessment in the Newborn
E X E R C IS E 44 . 1. 1 MAT E R N A L ASSESSMEN T
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
E X E R C IS E 44 . 1. 3 ID E NT IFIC ATION OF THE COMPON EN TS OF A T-PIECE RESUSCITATOR
Label the components of a T-piece resuscitator, as shown in Figure 44.1.
A. _____________________________________________________________________
B. _____________________________________________________________________
C. _____________________________________________________________________
D. _____________________________________________________________________
E. _____________________________________________________________________
2679_Ch44_733-748.indd 739 07/02/13 4:48 PM

E XE RCI SE 4 4 .1 . 4 R E S U S C ITAT IO N O F T H E N EW BORN
Apgar score: _____________________________________________
Charting: _____________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Scenario 2: Baby Girl A and Baby Girl B Williams
BABY GIRL A
Apgar score: _____________________________________________
Charting: _____________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
BABY GIRL B
Apgar score: _____________________________________________
Charting: _____________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
2679_Ch44_733-748.indd 740 07/02/13 4:48 PM

EXERCISE 44.2 Nasal Continuous Positive Airway Pressure for the Infant
Charting: _____________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________

1. For the following respiratory care procedures, identify the major differences between adult and pediatric care and
explain the rationale for the differences.
A. Oxygen therapy
B. Aerosol delivery
C. Suctioning
D. Airway care
E. Chest physiotherapy
F. Noninvasive monitoring
G. Blood gas analysis
2679_Ch44_733-748.indd 741 07/02/13 4:48 PM

2. Compare the 2010 American Heart Association’s guidelines for basic life support for infants, children, and adults in
the following components:
Recommendations
Component Adults Children Infants
Recognition
CPR Sequence
Compression Rate
Chest Wall Recoil
Compression Interruptions
Airway
Compression-to-Ventilation Ratio
Ventilations: When Rescuer Is Not Proficient
Ventilations With Advanced Airway (HCP)
Procedure for Ventilations With Advanced Airway (HCP)
Defibrillation
3. Why is the Apgar score not used to determine the need for resuscitation of the newborn?
4. What should be done for the newborn postresuscitation?
5. Why is it important for supplemental oxygen to be heated and humidified when administered to the newborn?
2679_Ch44_733-748.indd 742 07/02/13 4:48 PM


STUDENT: DATE:
NASAL CPAP INITIATION
PERFORMANCE LEVEL
PERFORMANCE RATING
Performance Level:
NA = Not applicable
Performance Rating:

2. Identifies the circuit components of a continuous flow CPAP circuit and assembles properly
3. Performs the required leak test (if applicable)

5. Turns the unit or system on and selects the proper mode, pressures, ramp or rise time, FIO2, and timed inspiration
6. Checks the alarm function and sets alarms
7. Positions the patient and applies the nasal prongs
8. Attaches the tubing to supports and confirms proper fit and comfort
9. Evaluates the waveforms to identify tidal volume, rate, pressures and flow, air trapping, or auto-PEEP
10. Adjusts the CPAP pressure to conform with the physician’s order
11. Reassess vital signs, SpO2, breath sounds, respiratory rate, and ventilatory status
12. Determines how the patient is tolerating the procedure, including effectiveness
FOLLOW-UP
2679_Ch44_733-748.indd 743 07/02/13 4:48 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch44_733-748.indd 744 07/02/13 4:48 PM


STUDENT: DATE:
OXYGEN HOOD
PERFORMANCE LEVEL
PERFORMANCE RATING
Performance Level:
NA = Not applicable
Performance Rating:


3. Connects the blender or air and oxygen flowmeters
4. Attaches the nebulizer or humidifier to the blender or flowmeters
5. Fills with sterile water if not prefilled or sets up the continuous feed system
6. Attaches the servo-controlled heater and plugs into an electrical outlet; sets the temperature to 32°–37°C
7. Adjusts blender or nebulizer to prescribed FIO2 or adjusts liter flow .7 Lpm
8. Attaches a large-bore tubing to the nebulizer outlet and oxygen hood inlet; uses a water drainage bag
9. Inserts the temperature probe in the appropriate location
10. Places the infant in the oxygen hood and loosely seals around the neck
11. Analyzes FIO2 at the infant’s mouth
12. Allows for warm-up time and adjusts the heater if necessary to ensure a neutral thermal environment
13. Assesses oxygenation and ventilation
FOLLOW-UP
14. Places the cap or unplugs analyzer when not in use
2679_Ch44_733-748.indd 745 07/02/13 4:48 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch44_733-748.indd 746 07/02/13 4:48 PM


STUDENT: DATE:
OXYGEN TENT
PERFORMANCE LEVEL
PERFORMANCE RATING
Performance Level:
NA = Not applicable
Performance Rating:

2. Educates the patient’s family on oxygen safety

4. Attaches the canopy to the tent frame
5. Connects the gas inlet and outlet hoses to the portholes of the canopy
6. Assembles the nebulizer and fills the reservoir with sterile water
7. Turns the unit on
8. Attaches the drain hose to the collection bottle
9. Attaches the high pressure hose to the oxygen flowmeter or 50 psi DISS outlet
10. Verifies mist production
11. Ensures that no electrical hazards are present
12. Places the tent over the bed and flushes the tent for 5 minutes
13. Places the infant or child in the tent
14. Analyzes FIO2
FOLLOW-UP
2679_Ch44_733-748.indd 747 07/02/13 4:48 PM


PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch44_733-748.indd 748 07/02/13 4:48 PM

CHAPTER Neonatal/Pediatric
Ventilation
INTRODUCTION During the last decade, many great advances have been made in perinatology, especially
in the area of newborn pulmonary disorders and neonatal ventilation. Further
refinements of conventional mechanical ventilation, along with a better understanding of
high-frequency ventilation, have improved outcomes for neonates. It is therefore
essential that the respiratory care practitioner (RCP) become clinically proficient with
these techniques. The RCP must develop the dexterity to set up mechanical ventilators
and the cognitive expertise to adjust ventilator parameters.
Although the physiological objectives for mechanical ventilation in the pediatric patient
are basically the same as those in adult patients, the pediatric patient presents with some
of the most challenging clinical situations in critical care.1
OBJECTIVES 1. Select, assemble, verify, and document the function of a time-cycled, pressure-controlled
Upon completion of this ventilator.
chapter, you will be able to: 2. Practice the documentation skills required for a neonatal or pediatric patient-ventilator
system check using a ventilator flow sheet and the skills necessary to generate a narrative
or shift note.
KEY TERMS
amplitude high-frequency ventilator
chest wiggle nasal continuous
circumoral positive airway
hertz (Hz) pressure (NCPAP)
749
2679_Ch45_749-766.indd 749 07/02/13 4:49 PM

Exercises
F 50-psi oxygen source F Oxygen analyzers
F 50-psig regulator F Pediatric care doll or mannequin
F Air compressor F Respiratory transfer set (continuous feed
F Blender system)
F Bourdon gauge and Thorpe tube flowmeters F Respirometer
F Endotracheal and tracheostomy tubes F Sterile water
F Endotracheal tube connector F Suction catheters
F HEPA bacteria filters F T-adapter with small-bore tubing connection
F High-frequency ventilator (optional) and cap
F High-pressure hoses F Temperature probes
F Infant lung simulator (optional) F Ventilator circuits (heated-wire circuits if
available)
F Infant/pediatric ventilators
F Watch with second hand
F Infant test lungs
F Water traps
F Infant ventilator circuits
F Wick humidifiers
F Manufacturers’ operation and maintenance
manuals (videos if available) F Wrenches
F Miller laryngoscope blades and handles
EXERCISE 45.1 TIME-CYCLED/PRESSURE-LIMITED VENTILATORS

EXERCISE 4 5.1.1 VEN TILATOR AS S E MB LY
1. Select an infant ventilator, water traps, bacteria filters, humidifier, and infant test lung or
mannequin. Record the ventilator make and model on your laboratory report.
2. Obtain the maintenance manual for the ventilator selected. In the manual, find the
manufacturer’s recommendations for the following:
Changing and cleaning of bacteria filters
Fan filters
Sterilization or disinfection instructions for internal and external parts and surfaces
Requirements for routine maintenance
Record this information on your laboratory report.
3. Locate the chronometer and record the number of hours of use on your laboratory report.
4. Assemble the ventilator as shown according to the manufacturer’s instructions.
EXERCISE 4 5.1.2 IDEN TIFIC ATION O F C O N T R O LS

1. On the same infant ventilator used in Exercise 45.1.1, identify the following controls. It is
important to note that not all ventilators have the same controls, but they have several
controls in common. Refer to Chapter 39.
High-pressure limit
Rate
Fio2
Flow
Inspiratory time
Expiratory time
Mode selection
Low inspiratory pressure
Low PEEP/CPAP
Low oxygen pressure
Low air pressure
Prolonged inspiratory pressure
Ventilator inoperative
Overpressure relief valve
2679_Ch45_749-766.indd 750 07/02/13 4:49 PM

C H A P T E R 45 | N E O N ATA L/ P E DIATR IC V ENTILATION • 751
2. Record the controls identified on your laboratory report.
EXER C ISE 45 .1 .3 MAN IPU LAT I O N O F C O N T R O LS

Mode = IMV or SIMV
PIP = 20 cm H2O
f = 20/minute
Flow rate = 9 Lpm
Inspiratory time = 0.4 second
PEEP = 5 cm H2O
Fio2 = 1.0
Make sure that all the alarms are set to the appropriate settings. Record the alarm settings
selected on your laboratory report.
2. Attach the infant test lung to the patient wye connection.
3. Observe the inflation of the test lung and record your observations on your laboratory
report.
4. Squeeze the test lung several times to simulate an inspiratory effort and rate of 40 breaths/
minute. Observe the manometer. Count the rate at which you are squeezing the test lung
and compare it with the displayed rate on the machine. Record the results on your
laboratory report.
5. Observe the test lung expansion and compare it with step 3. Record your observations on
6. Adjust the inspiratory time to 1 second. Squeeze the test lung at a minimum rate of 40
breaths/minute. Listen to the sound of the machine. Observe the manometer and alarms.
Record the results and observations on your laboratory report.
7. Observe the test lung expansion and compare it with step 5. Record the result on your
laboratory report.
8. Return the inspiratory time to 0.4 second. Decrease the rate to 5 breaths/minute.
10. Change the flow rate to 2 Lpm. Continue simulating spontaneous respirations at a rate of
40 breaths/minute. Observe the test lung expansion, manometer, and alarms. Record your
11. Change the flow rate to 12 Lpm. Continue simulating spontaneous respirations at a rate of
12. Return the flow to 9 Lpm. Adjust the PIP to 10 cm H2O. Continue simulating spontaneous
respirations at a rate of 40 breaths/minute. Observe the test lung expansion, manometer,
and alarms. Record your observations on your laboratory report.
13. Adjust the PIP to 30 cm H2O. Continue simulating spontaneous respirations at a rate of
EXERCISE 45.2 HIGH-FREQUENCY VENTILATORS
Audiovisual training 1. Obtain a high-frequency ventilator, if available. Set up the ventilator as shown in
videotapes are available Figure 45.1.
from several high-frequency 2. Attach a test lung to the circuit.
ventilator manufacturers. 3. Initiate high-frequency ventilation (HFV) using Table 45.1 as a guide.
Your instructor may have 4. Indicators for adequate inflation during HFV include the following1:
these available in the Chest x-ray findings
laboratory. Chest wiggle
Ptco2 and Ptcco2 values
Spo2
CST
Hemodynamic status
a/A ratio
Alveolar ventilation is directly proportional to the amplitude setting.2
2679_Ch45_749-766.indd 751 07/02/13 4:49 PM

Figure 45.1. High-frequency oscillator ventilator.
Table 45.1 Initial HFV Settings2

Frequency 15 Hz (900 bpm); range 6–15 Hz
(Premature Infants <2.5 kg)
6–12 Hz with air leaks
Inspiratory Time Fixed at 18 ms (0.018 sec)
I:E Ratio Dependent on rate
Amplitude 24 (11–51)
Adjust until vigorous chest wall vibrations seen
Titrate based on PaCO2
To change PaCO2 ± 2– 4mm Hg change amplitude 3 units
To change PaCO2 ± 5–9 mm Hg change amplitude 6 units
PEEP Equal to MAP on CMV
*bpm = beats per minute
5. Adjust the amplitude to 11. Observe the test lung and record your observations on your
laboratory report.
6. Adjust the amplitude to 51. Observe the test lung and record your observations on your
laboratory report.
7. Return the amplitude to 24. Adjust the settings to 10 Hz (600 beats or cycles/minute).
Determine the I:E ratio and record your answer on your laboratory report. Observe the test
lung and record your observations on your laboratory report.
8. Adjust the settings to 22 Hz (1,320 beats or cycles/minute). Observe the test lung and record
your observations on your laboratory report.
EXERCISE 45.3 INITIATING MECHANICAL VENTILATION IN AN INFANT

EXERCISE 45 .3 .1 S C EN AR IO 1
Baby Boy A is currently on NCPAP = 5 cm H2O and an Fio2 = 0.80. The following data are
obtained:
Spo2 = 85%
Ptcco2 = 75 mm Hg
Capillary stick pH = 7.20
1. The physician has asked you to initiate mechanical ventilation. Using Table 45.2 as a guide,
adjust the ventilator and initiate mechanical ventilation.
2. Perform a patient-ventilator system check, including “patient” assessment. Include oxygen
analysis and airway care. Record all pertinent data on the ventilator flow sheet provided in
2679_Ch45_749-766.indd 752 07/02/13 4:49 PM

Table 45.2 Initial Ventilator
Suggested Initial Ventilator Settings for Newborn Infants*
Parameters
With Normal Lungs With Noncompliant (Stiff) Lungs or RDS
PIP 12–18 cm H2O 20–25 cm H2O
Respiratory rate 10–20 breaths/min 20–40 breaths/min
PEEP 2–3 cm H2O 4–5 cm H2O
Flow rate 4–10 L/min 4–10 L/min
Inspiratory time 0.4–0.8 sec 0.3–0.5 sec
I:E ratio 1:2–1:10 1:1–1:3
FIO2 To maintain PaO2 >50 mm Hg To maintain PaO2 >50 mm Hg
*RDS = respiratory distress syndrome; PIP = peak inspiratory pressure; PEEP = positive end-expiratory pressure; I:E
ratio = inspiratory-expiratory ratio; FIO2 = fractional concentration of oxygen in inspired gas; PaO2 = partial pressure
of arterial oxygen
From Whitaker, K: Comprehensive Perinatal and Pediatric Respiratory Care. Delmar, Albany, 2001, p. 508, with permission.
3. A blood gas is obtained after your initial settings:

pH = 7.32
Pao2 = 120 mm Hg
Paco2 = 60 mm Hg
Adjust the ventilator settings according to Table 45.3. Perform a patient-ventilator system
check, including “patient” assessment. Include oxygen analysis and airway care. Record all
pertinent data on the ventilator flow sheet provided in your laboratory report.
4. Write a narrative note documenting your “patient’s” status and any other data required to
EXER C ISE 45 .3 .2 S C EN AR I O 2
Baby Girl B is a 26 weeks’ gestation neonate presently in the NICU receiving an Fio2 = 0.40 via
oxyhood. You have noticed increasing expiratory grunting, retractions, and periods of apnea and
bradycardia over the last hour. As you are suctioning the patient, she has a complete respiratory
arrest. The nurse is manually ventilating while you set up and initiate mechanical ventilation.
1. Select the appropriate size endotracheal tube and record your selection on your laboratory report.
2. Baby Girl B is now intubated. Determine the appropriate ventilatory parameters and initiate
ventilation. Perform a patient-ventilator system check, including “patient” assessment.
Include oxygen analysis and airway care. Record all pertinent data on the ventilator flow
3. A blood gas is obtained after your initial settings:
pH = 7.45
Paco2 = 35 mm Hg
Pao2 = 45 mm Hg
Adjust the ventilator settings according to Table 45.3. Perform a patient-ventilator system
check, including “patient” assessment. Include oxygen analysis and airway care. Record all
pertinent data on the ventilator flow sheet provided in your laboratory report.
Table 45.3 Suggested Neonatal

Setting Adjustment Increment Anticipated Results
Ventilator Adjustments
FIO2 2–5 (%) Change in PaO2
PIP +1–2 (cm H2O) Increased PaO2
Decreased PaO2
PEEP +1–2 (cm H2O) Increased PaO2
Decreased PaO2
T1 +0.1–0.2 (sec) Increased PaO2
–0.1–0.2 (sec) Better synchronization
Rate 2–5 (breaths per minute) Change in PaCO2
From Czervinske, MP, and Barnhart, SL: Perinatal and Pediatric Respiratory Care. WB Saunders, Philadelphia, 1995,
p. 81, with permission.
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EXERCISE 45.4 PEDIATRIC VENTILATION
Obtain an appropriate ventilator for pediatric patients, set it up, and verify the function. Record
the make and model on your laboratory report.
For each of the following scenarios, initiate mechanical ventilation according to the guidelines
outlined in Table 41.1.
Amanda Chung is an 8-month-old infant admitted with respiratory syncytial virus (RSV) pneu-
monia. She weighs 16 lb. Initial blood gases reveal the following:
pH = 7.15
Paco2 = 65 mm Hg
Pao2 = 40 mm Hg
1. Select the appropriate size and type of airway, and record your selection on your laboratory
report.
2. The physician asks you to determine the appropriate ventilatory mode and parameters and
initiate ventilation. Perform a patient-ventilator system check, including “patient”
assessment. Include oxygen analysis and airway care. Record all pertinent data on the
ventilator flow sheet provided in your laboratory report.
Chiam Goldfarb is a 3-year-old child brought to the emergency department unconscious
after ingestion of an unknown quantity of paint thinner. Initial assessment reveals a 35-lb,
well-nourished child with the following findings:
Pulse 140/minute
f = 45/minute with sternal retractions
Stridor
Nasal flaring
Breath sounds diminished with diffuse bilateral wheezes
Color pale with circumoral cyanosis
An attempt to intubate the child is unsuccessful due to severe glottic edema
1. Select the appropriate size and type of airway, and record your selection on your laboratory
report.
2. The physician asks you to determine the appropriate ventilatory mode and parameters
and initiate ventilation. Perform a patient-ventilator system check, including “patient”
assessment. Include oxygen analysis and airway care. Record all pertinent data on the
ventilator flow sheet provided in your laboratory report.
RE F E RE N CE S
1. Czervinske, MP, and Barnhart, SL: Perinatal and Pediatric Respiratory Care. WB Saunders, Philadelphia, 2003, p. 310.
2. Klein, JM: Management strategies with high frequency ventilation in neonates: Infant star ventilator. Presented at 41st Annual AARC
Convention, Orlando, FL, 1995.
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Laboratory Report
CHAPTER 45: NEONATAL/PEDIATRIC VENTILATION
Name: Date:
Data Collection
EXERCISE 45.1 Time-Cycled/Pressure-Limited Ventilators
E X E R C IS E 45 . 1. 1 V E NT ILAT O R ASSEMBLY
Ventilator make and model: _____________________________________________________________________________________
Manufacturer’s recommendations:
1. Changing and cleaning of bacteria filters: ______________________________________________________________________
____________________________________________________________________________________________________________
2. Fan filters: _______________________________________________________________________________________________
____________________________________________________________________________________________________________
3. Sterilization or disinfection instructions for internal and external parts and surfaces: ____________________________________
____________________________________________________________________________________________________________
4. Requirements for routine maintenance: ________________________________________________________________________
____________________________________________________________________________________________________________
Number of hours of use: ________________________________________________________________________________________
E X E R C IS E 45 . 1. 2 ID E NT IFIC ATION OF CON TROL S
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
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E XE RCI SE 4 5 .1 . 3 MA N IP U LAT IO N O F C O N T ROL S
Mode = IMV or SIMV
PIP = 20 cm H2O
f = 20/minute
Flow rate = 9 Lpm
Inspiratory time = 0.4 second
PEEP = 5 cm H2O
FIO2 = 1.0
Alarm settings: _______________________________________________________________________________________________
____________________________________________________________________________________________________________
Observation of the inflation of the test lung: ________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Spontaneous rate = 40 breaths/minute
Observation of the manometer: __________________________________________________________________________________
____________________________________________________________________________________________________________
Rate comparison: _____________________________________________________________________________________________
Comparison of test lung expansion with step 3: ______________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Inspiratory time = 1 second, spontaneous rate = 40 breaths/minute
Observation of the manometer and alarms: _________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Comparison of the test lung expansion with step 5: ___________________________________________________________________
____________________________________________________________________________________________________________
Inspiratory time = 0.4 second, rate = 5 breaths/minute, spontaneous rate = 0
Observation of ventilator response: _______________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Flow rate = 2 Lpm, spontaneous rate = 40 breaths/minute
Observation of the test lung expansion, manometer, and alarms: ________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
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Flow rate = 12 Lpm
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Flow rate = 9 Lpm, PIP = 10 cm H2O
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
PIP = 30 cm H2O
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
EXERCISE 45.2 High-Frequency Ventilators
Amplitude = 11
Observations: ________________________________________________________________________________________________
____________________________________________________________________________________________________________
Amplitude = 51
Observations: ________________________________________________________________________________________________
____________________________________________________________________________________________________________
Amplitude = 24; Frequency = 10 Hz (600 bpm)
Observations: ________________________________________________________________________________________________
____________________________________________________________________________________________________________
I:E ratio (show your work): ______________________________________________________________________________________
Observations: ________________________________________________________________________________________________
____________________________________________________________________________________________________________
Frequency = 22 Hz (1,320 bpm)
Observations: ________________________________________________________________________________________________
____________________________________________________________________________________________________________
2679_Ch45_749-766.indd 757 07/02/13 4:49 PM

EXERCISE 45.3 Initiating Mechanical Ventilation in an Infant
E XE RCI SE 4 5 .3 . 1 S C E NA R IO 1
Baby Boy A is currently on CPAP = 5 cm H2O and an FIO2 = 0.80. The following data are obtained: SpO2 = 85%, PTCCO2 = 75 mm Hg, capil-
lary stick pH = 7.20.
(Insert ventilator flow sheet at end of laboratory report.)
“Charting”: __________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Size endotracheal tube: ________________________________________________________________________________________
“Charting”: __________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
EXERCISE 45.4 Pediatric Ventilation
Make and model of ventilator: ___________________________________________________________________________________
Size and type of airway: ________________________________________________________________________________________
“Charting”: __________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Size and type of airway: ________________________________________________________________________________________
2679_Ch45_749-766.indd 758 07/02/13 4:49 PM

“Charting”: __________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

1. Explain how an incorrect flow rate setting (too high and too low) on a pressure-limited time-cycled ventilator affects
the volume delivered.
2. Compare and contrast mechanical ventilation of an adult with mechanical ventilation of an infant. Be sure to include
similarities and differences.
3. When using a time-cycled/pressure-limited ventilator, what will happen when the preset time limit is reached?
4. A neonatal patient who is intubated and has been placed on a time-cycled/pressure-limited ventilator has just received
surfactant replacement therapy. What is the most important parameter to adjust following the surfactant replacement
therapy? Why?
5. When ventilating the patient on a time-cycled/pressure-limited ventilator, what parameters determine the tidal volume
delivered? How can these values increase tidal volume? How can they decrease tidal volume?
2679_Ch45_749-766.indd 759 07/02/13 4:49 PM


PT ID:
DATE
TIME
MODE
SET RATE
TOTAL RATE
SET FIO2
ANALYZED FIO2
PEEP/CPAP
FLOW/%I-TIME
I:E RATIO
SENSITIVITY
PIP
PLATEAU
MAP
GAS TEMP
HIGH P
LOW P
LOW VT/VE
HI/LOW O2
LOW PEEP/CPAP
TEMP ALARM
TUBE SIZE/TYPE
TUBE PLACEMENT
CUFF PRESS
SpO2
PECO2
BP
HR
ECG
TEMP
pH
PaCO2
COHB/METHB
C.O.
PAP
PWP
PvO2
SvO2
CavO2
SIGNATURE
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2679_Ch45_749-766.indd 762 07/02/13 4:49 PM

STUDENT: DATE:
NEONATAL/PEDIATRIC VENTILATOR INITIATION

PERFORMANCE LEVEL
PERFORMANCE RATING
Evaluator: Setting:
Performance Level:
NA = Not applicable
Performance Rating:

2. Connects the ventilator to the appropriate emergency electrical outlets
3. Connects the high pressure hoses to the appropriate 50-psi gas source outlets
4. Attaches circuit, filters, and humidification systems as needed
5. Turns on the ventilator and performs any required tests
6. Performs any additional leak tests; corrects and verifies ventilator function

8. Evaluates the patient by assessing:
A. Vital signs, color, WOB, pulse oximetry, capnography, and transcutaneous monitoring
B. Physical assessment of the chest
C. Airway size, type, placement, and patency
D. Auscultation
E. Suctioning
9. Selects initial ventilator settings according to order or protocol
10. Sets the initial alarm parameters
11. Connects the patient to the ventilator and adjusts the following as needed:
A. Ventilator parameters and alarms G. Pressure support
B. Sensitivity H. Flow rate/I-time% flow pattern /I:E ratio
C. Mode I. Analyzes and adjusts FIO2 as indicated
D. Rate/frequency J. Adjusts the circuit humidification system
E. VT/VE K. Observes and interprets the ventilator graphics
F. PIP L. Notes the LOC, use of sedation, and paralytics
12. Completes a patient-ventilator system check
FOLLOW-UP
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PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch45_749-766.indd 764 07/02/13 4:49 PM


STUDENT: DATE:
NEONATAL/PEDIATRIC PATIENT-VENTILATOR SYSTEM CARE

PERFORMANCE LEVEL
PERFORMANCE RATING
Evaluator: Setting:
Performance Level:
NA = Not applicable
Performance Rating:


3. Assesses patient by performing/observing:
A. Vital signs
B. Physical examination of the chest
C. Auscultation
D. Airway placement and patency
E. Pulse oximetry or transcutaneous monitor
F. TCCO2
G. ECG
4. Assesses airway size and placement
5. Performs humidifier maintenance
6. Analyzes the FIO2
7. Measures and records the gas temperature
8. Verifies all ventilator settings and adjusts if necessary
9. Verifies all alarm settings and adjusts if necessary
10. Measures the spontaneous respiratory rate and volume if indicated
11. Measures the I:E ratio
FOLLOW-UP
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PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch45_749-766.indd 766 07/02/13 4:49 PM

CHAPTER Respiratory Care in
Alternate Settings
INTRODUCTION The exercises found throughout this laboratory manual cover the core skills necessary
to effectively perform an array of diagnostic and therapeutic respiratory therapy
procedures. In today’s health-care environment, these procedures are no longer
restricted to the acute care setting. Many of these same skills are required in alternate
care sites such as long-term care, subacute care, acute rehabilitation, nursing homes,
and physician’s offices. Additionally, these same skills often need to be adapted to suit
the home care environment. This chapter focuses on the unique aspects of providing
respiratory care in these alternate settings. In particular, this chapter covers aspects of
discharge planning, predischarge home assessment, and respiratory modalities often
found in alternate sites such as home oxygen therapy.
OBJECTIVES 1. Help formulate an effective discharge plan.

Upon completion of this 2. Set up, assemble, monitor, and maintain O2 therapy equipment in alternative settings.
3. Demonstrate the safe handling and refilling of a portable liquid oxygen system.
4. Identify the component parts and troubleshoot an oxygen concentrator.
5. Understand the special challenges that exist in providing other therapeutic modalities,
including ventilatory support outside the acute care hospital.
6. Perform a home evaluation.
7. Instruct patients or caregivers and confirm their ability to provide postacute care.
8. Understand proper documentation regarding patient evaluation and progress in postacute care.
used in alternate patient care settings.
KEY TERMS
Centers for Medicare Certificate of Medical oxygen-conserving
& Medicaid Services Necessity (CMN) devices
(CMS) oxygen concentrator
767
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Exercises
F Demand-flow regulator F Portable liquid oxygen tanks
F Disinfection solution F Portable ventilator
F Oxygen concentrator F Reservoir cannula
F Pendant cannula F Ventilator circuits
EXERCISE 46.1 LONG-TERM OXYGEN THERAPY
1. Perform an Internet search to investigate what documentation is required for home or long-
term oxygen therapy by Medicare or other insurance providers and record them on your
laboratory report.
2. Based on your research, identify the essential components of a home oxygen therapy
prescription and record them on your laboratory report.
3. How may a patient “qualify” for home oxygen reimbursement in accordance with Centers
for Medicare & Medicaid (CMS) guidelines?1 Record the required qualifications on your
laboratory report.
4. Describe the purpose of a Certificate of Medical Necessity (CMN) as shown in Figure 46.1.
Record the purpose on your lab report.
5. Determine the most suitable type of home oxygen supply system for the following:
A. Patients requiring increased mobility for professional, social, and/or medical reasons
B. Patients with limited mobility
Record your recommendations on your laboratory report.
6. Coordination with other medical disciplines involved with the patient’s discharge is essential.
List the role of the following disciplines in the discharge plan in your laboratory report:
discharge planning coordinator, nurse, physical therapist, occupational therapist, and social
worker.
7. Describe other steps the respiratory therapist will need to take to ensure that the patient and
caregivers are using the oxygen therapy equipment safely and effectively. Record the steps in
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C H A P T E R 46 | R E S P I R AT O RY C A R E I N ALTER NATE S ETTINGS • 769
Figure 46.1. Certificate of Medical Necessity (CMN) for qualifying home oxygen patients for reimbursement from the Centers of Medicare & Medicaid Services (CMS).
This form (CMS 484) is available at http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms484.pdf.
2679_Ch46_767-800.indd 769 08/02/13 10:19 AM

EXERCISE 46.2 PORTABLE LIQUID OXYGEN SYSTEMS
1. Identify the following components of a portable liquid system, as shown in Figure 46.2, and
record the labeled parts on your laboratory report.2
Continuous-demand flow switch
Vent valve
Oxygen level indicator
Fill connector location
Carrying strap
Inspiration sensor connector
Oxygen tube connector
Flow control knob
2. Connect and refill a portable cylinder from the main cylinder.
A. Check the reservoir contents indicator to ensure an ample supply.
B. Check the pressure gauge on the reservoir to be sure that the needle is in the “normal”
region.
C. Turn the flow control to zero.
D. Remove the dust cap from the reservoir fill connector. Check for the presence of
moisture. If moisture exists, wipe it with a lint-free cloth.
E. Lower the unit into position so that the unit connector enters the reservoir connector.
F. Rotate the unit in a clockwise direction until the roller gently drops into the slot in
the reservoir connector.
G. Move the vent valve into the open position. This will result in a loud hissing noise.
The unit is now filling.
H. When the hissing changes sound and a dense white vapor surrounds the cover, close
the vent valve.
I. Disengage the unit.
D
C
Figure 46.2. Components of a portable liquid oxygen system. H
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C H A P T E R 46 | R E S P I R AT O RY C A R E I N A LTER NATE S ETTINGS • 771
EXERCISE 46.3 OXYGEN CONCENTRATORS
1. Identify the following components of an oxygen concentrator and record the labeled parts in
Figure 46.3 on your laboratory report.2
Electrical connector
On/off switch
Flowmeter
Filter
Oxygen connection
Alarm (not shown)
Battery for the alarm (not shown)
2. Turn the concentrator on. Turn the flowmeter to 3 Lpm. Attach an Erie test flowmeter to the
concentrator flowmeter and record the reading on your laboratory report.
3. Unplug the concentrator and record your observations on your laboratory report.
E
A
Figure 46.3. Components of an oxygen concentrator.
EXERCISE 46.4 OXYGEN-CONSERVING DEVICES2
Describe what types of patients are suitable for an oxygen-conserving device that increases dura-
tion of flow. What are two advantages of oxygen-conserving devices, such as conserving cannulas
and pulse-dose regulators? Record your answers on your laboratory report.
EX ERCIS E 4 6.4.1 CON S ERV I N G / R E S E R V O I R C A N N U LA S

1. Note the features of both the pendant cannula and the mustache reservoir cannula, as shown
in Figures 46.4 and 46.5.
2. Using a mannequin or your lab partner, set up a conserving device.
A. Connect the reservoir cannula tubing to oxygen sources.
B. Adjust oxygen flow per manufacturer’s specifications. At lower flows, the liter flow may
be reduced by about half with a conserving cannula.
C. Connect the cannula to patient.
D. Assess the patient and monitor his or her response to the oxygen-conserving device.
2679_Ch46_767-800.indd 771 08/02/13 10:19 AM

Figure 46.4. Oxygen-conserving devices: mustache reservoir

cannula. (Courtesy of Cardinal Health, Dublin, OH.)
Figure 46.5. Oxygen-conserving devices: pendant cannula.

(Courtesy of Cardinal Health, Dublin, OH.)
EXERCISE 4 6 .4 .2 DEMAN D-FL OW R E G U LAT O R S

1. Examine a demand-flow regulator and note the key features, as shown in Figure 46.6.
2. Using a mannequin or your lab partner, set up a demand-flow regulator.
A. Connect the pulse-dose regulator to a gaseous tank or portable liquid system.
B. Connect the cannula to the pulse-dose regulator.
C. Turn on the pulse-dose regulator.
D. Check the battery if the unit will not turn on.
E. If the unit is functioning properly, connect the cannula to the patient.
F. Assess the patient and monitor his or her response to the oxygen-conserving device.
Figure 46.6. Demand-flow oxygen regulator.

(Courtesy of Cardinal Health, Dublin, OH.)
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EXERCISE 46.5 HOME DISINFECTION TECHNIQUES
1. Describe why it is important to use disposable respiratory supplies and equipment whenever
possible in alternate sites. Record your answer on your laboratory report.
2. Review the steps in cleaning and disinfecting respiratory supplies, and record them on your
laboratory report.
EXERCISE 46.6 HOME CARE/PORTABLE VENTILATOR INITIATION4

E X ERCIS E 4 6.6.1 ALAR MS
1. Select a home care ventilator. Compare the alarms available on the home care ventilator with
the alarms available on the critical care ventilator. Record the alarms available on the home
care ventilator on your laboratory report.
2. Plug the unit into an electrical outlet.
3. Set the following parameters:
VT = 600 mL
f = 12/minute
4. Turn the unit on.
5. After several breaths, unplug the power source. Record your observations and the activated
alarms on your laboratory report.
6. Reset the alarm and connect the ventilator to an external 12-volt power source according to
the manufacturer’s recommendations. Record your observations and the activated alarms on
7. Reset the alarm.
8. Switch the power source back to the wall outlet.
E X ERCIS E 4 6.6.2 VEN TILAT O R I N I T I AT I O N U S I N G A H O ME C A R E / P O R TA B L E V E N T I L AT O R

Scenario
In this scenario, initiate You are working in a ventilator-dependent quadriplegia unit. You are called to initiate ventilation
ventilation using the home on the new admission, a 17-year-old male with a transverse myelitis of C2. The patient is alert
care ventilator from the but apprehensive. He is trached with a size 7 Portex tube with the cuff partially inflated to allow
previous exercise. Be sure a large enough leak to permit phonation. The physician requests the following settings:
to set all alarms. Mode = Assist/Control
VT = 1.0 L
Fio2 = 0.30
PEEP = 5 cm H2O
1. Set the initial ventilator settings. Select any additional parameters according to protocol but
not ordered and record them on your laboratory report.
Vital signs
Auscultation
Suctioning
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EXERCISE 46.7 DISCHARGE PLANNING5
1. Describe the documentation necessary for discharge and for equipment to be set up at home
(or alternate site). Record them on your lab report.
2. Review the additional steps that should be followed prior to a patient’s discharge to home or
alternate site that needs respiratory equipment such as oxygen therapy.
A. Assess the patient’s clinical readiness for discharge and confirm no contraindications to
discharge.
B. Coordinate with other members of the discharge planning team (e.g., social work,
nursing, physical therapy).
C. Ensure that the home care company/equipment supplier has received the following
“intake information”:
i. Patient demographic (name, address, phone, alternate contact) information
ii. Physician prescription
iii. Certificate of Medical Necessity (for home oxygen under Medicare)
iv. Insurance information, verification of approval
D. Hold equipment training sessions with the caregivers, receive an adequate return
demonstration, and document their competency.
E. For high-tech equipment such as ventilators, trial the patient on home care equipment
while in the hospital, for at least 24 hours before actual discharge.
F. Assess the home (or alternate site) environment (see Exercise 46.8).
G. Ensure the equipment is delivered, functional, and properly set up prior to discharge.
H. Upon arrival at the home, set up the patient on the equipment, assess the patient, and
document.
I. Follow-up with the patient and caregiver to ensure proper functioning of the equipment
and that the patient is tolerating the home respiratory therapy.
3. Indicate what steps you would follow upon a patient’s arrival at home to ensure his or her
safety and that he or she is tolerating the home respiratory therapies. Record them on your
lab report.
4. Describe how you would follow up and document for such a patient once he or she is home.
Record your description on your lab report.
EXERCISE 46.8 HOME EVALUATION ASSESSMENT
1. Describe the steps you would follow prior to conducting a home evaluation assessment.
Record the steps on your laboratory report.
2. Indicate the considerations you would use to evaluate each of the following components of a
home evaluation assessment.6 Record them on your laboratory report.
A. Cleanliness and infection risk
B. Safety risk assessment
i. Fire/smoke risk
a. Appropriate number and placement of smoke and CO detectors
b. “No Smoking” signs properly placed, if oxygen is in use
c. Absence of high-risk alternate heat sources (e.g., space heaters)
d. Proper placement and precautions for any fireplace or wood stove
ii. Fall risks
a. Appropriate use of handrails
b. Safety precautions for stairs and ramps
c. Patient assessed for risk of falling
C. Adequacy of electric outlets
i. Adequacy of the number and placement of outlets
ii. Grounded outlets
iii. Adequacy of electrical outlet/circuit amperage
D. Adequacy of heating and cooling systems
E. Space for placement and storage of equipment and supplies
F. Access to and throughout home via ramps, lifts, and other adaptive devices
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C H A P T E R 46 | R E S P I R AT O RY C A R E I N ALTER NATE S ETTINGS • 775
G. Adequacy of doorways/hallways widths
H. Adjacency considerations (e.g., nearby bathroom)
I. Proper means for outside communication (e.g., phone)
J. Emergency/evacuation plan in place
3. Describe how you would document the assessment results of each area, including any
deficiencies or necessary adjustments. Record your description on your lab report.
4. Indicate what parties you would inform regarding the results of a home evaluation
assessment. Record them on your laboratory report.
REFERENCES
1. U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, CMS Manual, Instructions for Completing
the Certificate of Medical Necessity for Oxygen, 2005.
3. American Association for Respiratory Care: AARC clinical practice guideline: Suctioning of the patient in the home. Respir Care 44:
99–104, 1999.
4. American Association for Respiratory Care: AARC clinical practice guideline: Long-term invasive mechanical ventilation in the home:
2007 Update. Respir Care 52:1056–1062, 1995, 2007.
5. American Association for Respiratory Care: AARC clinical practice guideline: Discharge planning for the respiratory care patient.
Respir Care 40:1308–1312, 1995.
6. Wilkins, R, Sheldon, R, and Krider, S: Clinical Assessment in Respiratory Care, ed. 5. Mosby, St. Louis, 2005.
2679_Ch46_767-800.indd 775 08/02/13 10:19 AM

2679_Ch46_767-800.indd 776 08/02/13 10:19 AM
Laboratory Report
CHAPTER 46: RESPIRATORY CARE IN ALTERNATE SETTINGS
Name: Date:
Data Collection
EXERCISE 46.1 Long-Term Oxygen Therapy
Required documentation: ________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
List four essential components of a home oxygen therapy prescription: ____________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Indicate the two blood oxygen measurements that may be used to “qualify” for home oxygen coverage under Medicare:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Describe the purpose of a Certificate of Medical Necessity as shown in Figure 46.1: __________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Determine the most suitable type of home oxygen supply system.
A. For patients requiring increased mobility for professional, social, and/or medical reasons: ___________________________________
_____________________________________________________________________________________________________________
B. For patients with limited mobility: _______________________________________________________________________________
_____________________________________________________________________________________________________________
Coordinating roles in the discharge plan:
Discharge planning coordinator: __________________________________________________________________________________
_____________________________________________________________________________________________________________
2679_Ch46_767-800.indd 777 08/02/13 10:19 AM

Nurse: _______________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Physical therapist: _____________________________________________________________________________________________
_____________________________________________________________________________________________________________
Occupational therapist: _________________________________________________________________________________________
_____________________________________________________________________________________________________________
Social worker: _________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Describe other steps to ensure the patient and caregivers are using the oxygen therapy equipment safely and effectively: ____________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
EXERCISE 46.2 Portable Liquid Oxygen Systems
Identify the components of the portable liquid system, as shown in Figure 46.2.
A. __________________________________________________________________________________________________________
B. __________________________________________________________________________________________________________
C. __________________________________________________________________________________________________________
D. __________________________________________________________________________________________________________
E. __________________________________________________________________________________________________________
F. __________________________________________________________________________________________________________
G. __________________________________________________________________________________________________________
H. __________________________________________________________________________________________________________
EXERCISE 46.3 Oxygen Concentrators
Identify the components of the oxygen concentrator, as shown in Figure 46.3.
A. __________________________________________________________________________________________________________
B. __________________________________________________________________________________________________________
C. __________________________________________________________________________________________________________
D. __________________________________________________________________________________________________________
E. __________________________________________________________________________________________________________
2679_Ch46_767-800.indd 778 08/02/13 10:19 AM

FLOW = 3 Lpm: ________________________________________________________________________________________________
Observations: _________________________________________________________________________________________________
_____________________________________________________________________________________________________________
EXERCISE 46.4 Oxygen-Conserving Devices
Patients suitable for oxygen-conserving devices: _____________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
List two advantages of oxygen-conserving devices, such as conserving cannulas and pulse-dose regulators:
1. __________________________________________________________________________________________________________
2. __________________________________________________________________________________________________________
EXERCISE 46.5 Home Disinfection Techniques
Explain the importance of using disposable respiratory supplies and equipment in alternate sites: _______________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Describe the key steps for cleaning and disinfecting a nondisposable large-volume nebulizer: __________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
EXERCISE 46.6 Home Care/Portable Ventilator Initiation
E X E R C IS E 46 . 6. 1 A L A R MS
Comparison of available alarms: ___________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Alarm observations: ____________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
2679_Ch46_767-800.indd 779 08/02/13 10:19 AM

E XE RCI SE 4 6 .6. 2 V E NT ILAT O R INIT IAT IO N USIN G A HOME CARE/PORTABL E VEN TIL ATOR
RECORD VENTILATOR SETTINGS
Additional parameters: __________________________________________________________________________________________
RECORD INITIAL ALARM SETTINGS
High/low pressure: _____________________________________________________________________________________________
High/low minute volume and tidal volume (if applicable): ________________________________________________________________
High/low respiratory rate (if applicable): ____________________________________________________________________________
EXERCISE 46.7 Discharge Planning
Required documentation: ________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Safety: _______________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Follow-up documentation: _______________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
EXERCISE 46.8 Home Evaluation Assessment
Steps to be followed prior to a home evaluation: ______________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
EVALUATION CONSIDERATIONS
Cleanliness: __________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Safety: _______________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
2679_Ch46_767-800.indd 780 08/02/13 10:19 AM

Electrical outlets: ______________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Heating/cooling: _______________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Storage space: ________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Home access: _________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Doorway/hallway width: _________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Adjacency considerations: _______________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Communication devices: _________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Evacuation plan: _______________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Documenting the assessment results: ______________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Parties to be informed regarding the results: _________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
2679_Ch46_767-800.indd 781 08/02/13 10:19 AM


1. What oxygen supply system would you recommend for a homebound patient needing continuous low-flow oxygen?
2. An oxygen-dependent patient is receiving oxygen at 2 Lpm, requires extensive mobility, and frequently leaves his or her
home. Describe the ideal home supply system for this patient.
3. A patient using home oxygen calls to indicate that his portable liquid tank “hisses” when it is knocked on its side.
What is your assessment of the “problem” and how would you respond to this patient?
4. You are a home care respiratory therapist and your office calls and asks you about the feasibility of taking a ventilator
patient home the following day. What considerations should you keep in mind regarding your response?
5. For the scenario described in question 4, list at least three essential factors that would need to be established before the
patient could be discharged.
6. While you are performing a home assessment evaluation for a wheelchair-bound and ventilator-dependent patient
scheduled to be discharged, the caregivers initially indicate that they plan to use the unfinished attic as the patient’s
bedroom.
A. What concerns might you have regarding setting up the attic for this purpose?
B. To whom would you convey your concerns and how would you document these concerns?
2679_Ch46_767-800.indd 782 08/02/13 10:19 AM

7. What are the CDC’s recommended disinfectant solutions for the home care setting?
8. What infection control practices should you employ when making home care visits?
2679_Ch46_767-800.indd 783 08/02/13 10:19 AM

2679_Ch46_767-800.indd 784 08/02/13 10:19 AM

STUDENT: DATE:
OXYGEN-CONSERVING DEVICES
PERFORMANCE LEVEL
PERFORMANCE RATING
Performance Level:
NA = Not applicable
Performance Rating:


3. Attaches the appropriate oxygen delivery device to the appropriate gas source
4. Adjusts the liter flow as needed
5. Places the oxygen delivery device on the patient
6. Ensures that the conserving device is working properly, especially if a pulse-dose valve is in use
7. Ensures patient comfort
FOLLOW-UP
2679_Ch46_767-800.indd 785 08/02/13 10:19 AM


PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch46_767-800.indd 786 08/02/13 10:19 AM


STUDENT: DATE:
DISCHARGE PLANNING
PERFORMANCE LEVEL
PERFORMANCE RATING
Performance Level:
NA = Not applicable
Performance Rating:

2. Verifies consideration for transfer to an alternate care site (including home)

4. Evaluates the patient’s medical condition
5. Performs a site evaluation for continuing care (see PCE for Home Care Evaluation)
6. Evaluates patient’s financial resources
7. Evaluates the physical environment
8. Develops the discharge plan, including:
A. Integration into the community
B. Self-care
C. Roles and responsibilities of team members for daily care management
D. Documented mechanism for securing and training additional caregivers
E. Alternate emergency and contingency plans
F. Use, maintenance, and troubleshooting of equipment
G. Monitoring and appropriate response to changes in medical condition
H. Medication administration
I. Method for ongoing assessment of outcomes
J. Time frame for implementation
K. Method to assess growth and development of pediatric patients
L. Mechanism of communication among team members
M. Method of follow-up
9. Conducts education and training with documentation of competencies:
A. Education, training, and assessment tools to be used
B. Amount of time anticipated to complete the process
C. Team member access to the patient and family for information gathering and training
D. Source and limits of funds to implement plan
FOLLOW-UP
10. Assesses the patient’s progress and conducts follow-up education and training as needed
2679_Ch46_767-800.indd 787 08/02/13 10:19 AM


PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch46_767-800.indd 788 08/02/13 10:19 AM


STUDENT: DATE:
HOME CARE EVALUATION
PERFORMANCE LEVEL
PERFORMANCE RATING
Performance Level:
NA = Not applicable
Performance Rating:


3. Assesses the patient’s medical condition, including:
A. General condition, sensorium, anxiety, pain, and depression F. Patient and family psychosocial condition, including:
B. Nutritional status 1) Language or other barriers to communication
C. Respiratory and ventilatory support required 2) Level of cooperation
D. Other respiratory care equipment required 3) Depression, anger, and anxiety
E. Physical and functional ability including ADLs 4) Role and role reversal
5) Alcohol or medication abuse
6) Religious or cultural factors
4. Reviews/establishes goals of care, including:
A. Treatment of acute conditions D. Assurance of optimal quality of life
B. Weaning E. Patient’s and family’s desire for medical and ventilator care;
C. Rehabilitation advance directives
5. Arranges the date and time of an evaluation with the patient and/or family and other team members
6. Performs a site evaluation for continuing care, including:
A. Availability of caregivers and/or adequate 24-hour coverage 16)Adequate storage facilities
B. The caregiver’s ability to perform care (home discharge) 17)Precautions for allergies and dust mites
C. Analysis of the layout of the house, including: 18)Adequate personal hygiene and equipment cleaning
1) Size of rooms and doorways facilities
2) Location of windows 19) Telephone
3) Electrical outlets D. Capability of operating, maintaining, and support-
4) Room arrangement and stairs ing required equipment:
5) Safety and suitability 1) Type, method of application, and duration
6) Free from fire, health, and safety hazards 2) Other respiratory care equipment
7) Clear walkways 3) Oxygen therapy
8) No throw rugs 4) Aerosol therapy
9) Water supply: well or municipal 6) Monitoring and diagnostic procedures
10) Provision of fire extinguishers and smoke alarms 7) Treatment for sleep-disordered breathing
11) Provision of adequate heating, cooling and ventilation, E. Other ancillary equipment
filtration, and humidification systems 1) Suction
12) Provision of adequate electrical service 2) Nutritional therapy
13) Adequate lighting 3) Intravenous therapy
14) Backup generator 4) Adaptive equipment
15) Provision for patient access and mobility with adequate
patient space
FOLLOW-UP
8. Arranges the date and time of the reevaluation and plan development with the patient and/or family and other team members
2679_Ch46_767-800.indd 789 08/02/13 10:19 AM


PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch46_767-800.indd 790 08/02/13 10:19 AM


STUDENT: DATE:
HOME CARE VENTILATION
PERFORMANCE LEVEL
PERFORMANCE RATING
Performance Level:
NA = Not applicable
Performance Rating:

2. Instructs the family and caregivers on:
A. Importance of compliance and safety considerations
B. Comprehension of disease process as it relates to the prescription

4. Assesses the patient, including WOB, breath sounds, sensorium, color, SpO2, and airway patency
5. Demonstrates infection control procedures to the patient and/or caregiver
6. Instructs the patient and/or caregiver on:
A. Circuit assembly D. Oxygen equipment
B. Control settings E. Accessory equipment
C. Alarm settings
A. Type and function of airway D. Stoma care
B. Airway aspiration E. Dressing care
C. Tube care/cleaning F. Cuff maintenance
A. Equipment cleaning and disinfection
B. Troubleshooting
C. Emergency protocols
9. Charges the battery pack
10. Attaches the circuit and filters; performs a leak test
11. Sets the initial vent setting according to order or protocol
12. Sets the alarms; verifies function
13. Connects the patient to the home ventilator and adjusts settings as needed
14. Performs a patient/ventilator system check
FOLLOW-UP
2679_Ch46_767-800.indd 791 08/02/13 10:19 AM


PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch46_767-800.indd 792 08/02/13 10:19 AM


STUDENT: DATE:
HOME OXYGEN ADMINISTRATION
PERFORMANCE LEVEL
PERFORMANCE RATING
Performance Level:
NA = Not applicable
Performance Rating:


3. Applies knowledge of:
A. Disease process and relevance of prescription
B. Importance of patient compliance with therapy and safety considerations
4. Applies knowledge of:
A. Concentrator function
B. Inlet filter cleaning protocol
C. Nebulizer/humidifier maintenance
D. Response protocol for power/device failure
E. Activation of backup system with appropriate liter flow
F. Back-up duration per liter flow computation
G. Liquid portable oxygen systems; calculation of tank duration
H. Oxygen-conserving devices (pulse-dose demand systems, transtracheal oxygen devices, pendant or mustache cannulas); adjusts
liter flow to 1⁄2 of cannula setting
5. Demonstrates comprehension of backup system deactivation and purging
6. Verbalizes replacement tank procurement per provider protocol
7. Communicates appropriately with the patient, family, and instructor
8. Presents and explains emergency preparedness
9. Demonstrates the appropriate infection control procedures; maintains/processes equipment; disposes of infectious waste
10. Makes any necessary recommendations or modifications to the care plan
2679_Ch46_767-800.indd 793 08/02/13 10:19 AM


PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch46_767-800.indd 794 08/02/13 10:19 AM


STUDENT: DATE:
HOME NEBULIZER ADMINISTRATION
PERFORMANCE LEVEL
PERFORMANCE RATING
Performance Level:
NA = Not applicable
Performance Rating:

2. Selects, assembles, and verifies the function of the appropriate equipment and supplies:
A. Nebulizer assembly
B. Medication and/or diluents
C. Compressor

4. Explains the purpose of the procedure and confirms the patient’s and/or caregiver’s understanding, including:
A. Prescription relevance to disease process
B. Importance of compliance to treatment process
C. Relevant pharmacology and dosage of medication for this treatment
5. Assesses the patient, including WOB, physical assessment, breath sounds, sensorium, color, and pulse oximetry
6. Instructs the patient and/or caregiver on treatment technique
7. Observes the patient and/or caregiver treatment technique; reinstructs if needed
FOLLOW-UP
9. Instructs the patient on appliance maintenance, cleaning, disinfection, and/or disposal
10. Presents and explains emergency preparedness documents to the patient, family, and/or caregiver
2679_Ch46_767-800.indd 795 08/02/13 10:19 AM


PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch46_767-800.indd 796 08/02/13 10:19 AM


STUDENT: DATE:
HOME CPAP APPLICATION
PERFORMANCE LEVEL
PERFORMANCE RATING
Performance Level:
NA = Not applicable
Performance Rating:

2. Reviews the results of sleep studies
3. Sets the unit to the appropriate CPAP level

5. Fits and instructs the patient on the application of the nasal mask or pillow (or other interface)
6. Has the patient demonstrate the application of the device; reinstructs if needed
7. Instructs the patient and/or caregiver on methods of cleaning/disinfection of:
A. Inlet filters
B. Appliance circuit
C. Facial cleansing protocol
8. Presents and explains emergency preparedness documents to the patient and/or caregiver
FOLLOW-UP
2679_Ch46_767-800.indd 797 08/02/13 10:19 AM


PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch46_767-800.indd 798 08/02/13 10:19 AM


STUDENT: DATE:
HOME APNEA MONITORING
PERFORMANCE LEVEL
PERFORMANCE RATING
Performance Level:
NA = Not applicable
Performance Rating:


3. Demonstrates the correct setup for the monitor
4. Correctly places the electrode and appliance
5. Correctly connects the patient to the device
6. Sets and verifies alarm protocol and function:
A. Aural distance
B. Caregiver reactions to alarm situations
7. Instructs the family and/or caregiver on documentation of the event record
8. Instructs the family and/or caregiver on:
A. Troubleshooting procedures
B. Internal battery maintenance
C. Electrode care
9. Instructs/reviews the family and/or caregiver in techniques of infant CPR
10. Presents and explains emergency preparedness documents to the parents
FOLLOW-UP
2679_Ch46_767-800.indd 799 08/02/13 10:19 AM


PERFORMANCE RATING:

COGNITIVE DOMAIN
modify care plan
PSYCHOMOTOR DOMAIN
AFFECTIVE DOMAIN

SIGNATURES
Student Comments:
2679_Ch46_767-800.indd 800 08/02/13 10:19 AM

APPENDIX Normal and Critical
Values, Formulas,
and Rules of Thumb
CONTENTS Alveolar-Arterial Oxygen Gradient (A-a Gradient) 805

Oxygen Content 805
Metric Conversions 802 Arterial 805
Body Weight 802 Venous 805
Body Surface Area (BSA) 802 A-V Difference 805
Calculation of Ideal Body Weight (IBW) 802 Estimation of Fio2 Needed for Desired Pao2 805
Temperature Conversions 802 Oxygenation Ratio 805
Patient Assessment 802 Classic Shunt Formula 805
Vital Signs 802 Modified Estimated Shunt 805
Normal Respiratory Rate (F) 802 Henderson-Hasselbach (H-H) Equation 805
Normal Heart Rate 802 Minute Ventilation/CO2 Disparity 806
Blood Pressure (BP) 802 Base Excess (BE) 806
Normal Temperature 802 Determination of Bicarbonate Need in Patients With
Lab Values 802 Metabolic Acidosis 806
CBC 802 Hemodynamics 806
· ·
Electrolytes 802 Estimated Shunt Equation: QS /QT 806
Chemistry 802 Fick Equation 806
Miscellaneous 802 Cardiac Index (CI) 806
Pulmonary Mechanics 802 Stroke Index (SI) 806
Respiration 804 Mean Arterial Pressure (MAP) 806
Respiratory Quotient (RQ) 804 Mean Pulmonary Artery Pressure 806
Lung Volumes and Capacities 804 Systemic Vascular Resistance (SVR) 806
Four Volumes 804 Pulmonary Vascular Resistance (PVR) 806
Four Capacities 804 Pharmacology 806
“Normal” Values for Lung Volumes and Drug Dilution 806
Capacities 804 Standard Adult Dosages for Aerosolized
Bedside Spirometry 804 Medications 806
Inspiratory:Expiratory Ratio 804 Pediatric Dosages 807
Critical Values 804 Patient Assessment (Critical Care) 807
Medical Gas Therapy: Other Equipment 804 Airway Resistance Estimated 807
Concentration of Gases in Atmosphere 804 Auto-PEEP 807
Duration of Flow: Compressed Gas Cylinders 804 ECG Tracings 807
Duration of Liquid Cylinder 804 Lead Placement 808
Total Flow of Gas Mixtures 804 Standard Bipolar Hookup 808
Oxygen Delivery Percentages 804 Precordial Lead Placement 808
Helium Mixtures: Conversion Factors 804 Artifact (Interference With Normal Tracing) 808
Humidity Deficits 804 Heart Rate Calculation 808
Gas Laws 804 Pulmonary Function 808
Airway Care 804 Accuracy of Spirometers 808
Suctioning 804 Validity of Spirometry 808
Suction Pressures 804 Race Correction for Nonwhites 808
Pediatric ET Tube Size 805 Changes in Surveillance Spirometry 808
Length of ET Tube Insertion 805 Expected Change Due to Aging Alone 808
Endotracheal Tube Placement 805 Preshift to Postshift Surveillance 808
Blood Gases 805 Annual Surveillance 808
Predicting Pao2 on Room Air Based on Age (1484) 805
Alveolar Air Equation 805
801
2679_APP_A_801-808.indd 801 07/02/13 4:42 PM

802 • AP PENDIX A | NORM AL AND CRI T I CAL VAL U E S , FO R M U LA S , A N D R U LE S O F T H U M B
METRIC CONVERSIONS LAB VALUES

1 L 1,000 mL CBC
1 in. 2.54 cm
Hemoglobin (Hb) 1216 g/dL (15)
1 kg 2.2 lb
Hematocrit (Hct) 35%50%
Weight kg 2.2 lb
White blood cells (WBCs) 5,00010,000 mm3
mm Hg 1.36 cm H2O
Red blood cells (RBCs) 5,000,000 mm3
cm H2O/1.36 mm Hg
Platelets 150,000350,000 per mm3
TEM PERATURE C ON VER S ION S

E LE C T R O LY T E S
( 5
°C °F 32 —
9) Potassium (K) 3.55.0 mEq/L
Sodium (Na) 135145 mEq/L
Chloride (Cl) 95105 mEq/L
( 9
)
°F °C — 32
5
Calcium (Ca) 510 mEq/L
Magnesium (Mg) 1.52.5 mEq/L
°K °C 273 Phosphorus (PO4) 1.72.6 mEq/L
C H E MI S T R Y
BODY WEIGHT
Blood urea nitrogen (BUN) 825 mg/dL
BODY SURFAC E AREA (BS A) Creatinine 0.51.5 mg/dL
Glucose 70110 mg/dL
(4 weight kg) Albumin 3.55.0 mg/dL
BSA ——————— 7
kg 90 Triglycerides 10190 blood lipid
Cholesterol 200 g/dL
Normal adult average BSA 2.54.2 m2 Creatine phosphokinase (CPK) 535 units/mL
120 indicates myocardial infarction (MI)
Myocardial bands (MB) 5% total
CALCULATION OF IDEAL BODY WEIGHT (IBW)
Rise within 46 hr of MI
Men IBW (lb) 106 (6 [height in inches 60]) Ratio of CPK/MB 2.2 males, 2.9 females → MI
Women IBW (lb) 105 (5 [height in inches 60]) Lactic dehydrogenase (LDH) 95200 units/L
Serum glutamic oxaloacetic acid (SGOT)
Normal 540 units/mL
PATIENT ASSESSMENT
VITAL SIGNS MI S C E LLA N E O U S
Normal Respiratory Rate (F) Alcohol (ethyl)
Normal 0%
Adult 1220 breaths/min 0.05 no significant influence
Child 2040 breaths/min 0.050.01 present
Infant 4060 breaths/min 0.100.15 influence reaction time
0.15 intoxication
Normal Heart Rate 0.25 severe
Adult 60100 bpm Urine output 100 mL/hr, 30 mL/hr renal failure
60 is bradycardia Theophylline: therapeutic range 1020 units/mL
100 is tachycardia 20 nausea, vomiting, diarrhea, anorexia (may occur at
Child 100120 bpm lower levels also)
Infant 120160 bpm 30 cardiac arrhythmias
40 seizures
Blood Pressure (BP) Digitalis: therapeutic range 0.52.2
2.5 indicates dig toxicity
120 Chloride—sweat electrolyte
Normal ———
80 50 mEq/L normal
60 C/F: induced with pilocarpine (direct parasympa-
140 thomimetic); must repeat twice for positive result
Hypertension ———
90
100 P U LMO N A R Y ME C H A N I C S
Hypotension ———
60 Compliance: V/P
Compliance CL 0.2 L/cm H2O
Normal Temperature Compliance CT 0.2 L/cm H2O
Compliance CLT 0.1 L/cm H2O
98.6°F 37°C
Resistance 0.51.5 cm H2O/L/sec
2679_APP_A_801-808.indd 802 07/02/13 4:42 PM

A P P E N D I X A | N O R M A L A N D C R I T I C A L VA LU E S , FO R M U LA S , A ND R ULES OF THUM B • 803
R ESPIR ATION B E D S I D E S P I R O ME T R Y
Respiratory Quotient (RQ) Tidal volume (VT) 57 mL/kg (average adult 500 mL
or 400700 mL)
Normal 0.8
Minute ventilation (V̇E) 610 L/min; VT f
VCO2 200 mL/min Alveolar ventilation (VA) 4.2 L/min; (VT VD) f
——— —————— Vital capacity (VC) 5070 mL/kg
VO2 250 mL/min
Respiratory exchange ratio or ventilation/perfusion Inspiratory:Expiratory Ratio
(V/Q) 0.8 (0.71.0)
I:E ratio—normal 1:2 or 1:3
VA 4L Inspiratory flow rate (Vi) 2030 Lpm
—— ——
QC 5L V̇E 3 estimated inspiratory flow
Peak flow 300600 Lpm
Anatomic VD 1 mL/lb or 2 mL/kg (average adult 150 mL)
Negative inspiratory force (NIF) or maximum inspiratory
Anatomic shunt 3%5% of CO (from azygous, bron-
pressure (MIP) 60 to 100 cm H2O
chial, thebesian cardiac veins)
Maximum voluntary ventilation (MVV) 100 to 200 Lpm;
Low V/Q 0.7 shunt
should approximate 35 FEV1
High V/Q 1.0 dead space
C R I T I C A L VA LU E S
LUN G VOLUMES AN D C A PA C I T I E S
Minimal values needed to sustain spontaneous breathing
Four Volumes (numbers less than these indicate impending respiratory
Tidal volume (VT): normal amount of air moved during failure):
inspiration or expiration, usually at rest
VC 1015 mL/kg for adequate cough, sigh
Inspiratory reserve volume (IRV): volume that can be
23 VT
inhaled after a normal inhalation
Expiratory reserve volume (ERV): volume that can be MIP (NIF) 20 to 25 cm H2O
exhaled after a normal exhalation Peak flow (asthmatics) 80100 Lpm ominous sign
Residual volume (RV): volume left in lungs after a maximal MVV 23 V̇E
exhalation RSBI (f/VT) 105
Four Capacities
MEDICAL GAS THERAPY: OTHER
Inspiratory capacity (IC): maximal amount of air inhaled EQUIPMENT
after a normal exhalation
Vital capacity (VC): maximal amount of air exhaled after a C O N C E N T R AT I O N O F G A SE S I N
maximal inhalation AT MO S P H E R E
Functional reserve capacity (FRC): amount of air left in
lungs after a normal exhalation Normal atmospheric barometric pressure (PB) at sea level:
Total lung capacity (TLC): amount of air in lungs after a PB 760 mm Hg
maximal inhalation PB 14.7 psi
IC IRV VT PB 29.92 in Hg
TLC IRV VT ERV RV Major gases:
TLC IC FRC
TLC VC RV N2 78.3%
TLC IC ERV RV O2 20.9%
TLC IRV VT FRC
Trace gas:
VC IRV VT ERV
VC IC ERV CO2 0.04%
VC TLC RV
Partial pressure of gases in alveoli: PB 760 mm Hg
FRC ERV RV
FRC TLC IC N2 573 mm Hg
O2 100 mm Hg
“Normal” Values for Lung Volumes CO2 40 mm Hg
and Capacities H2O 47 mm Hg
Total 760 mm Hg
VT 500 mL
IC 3,500 mL Dalton’s law: sum of partial pressure of a gas (Pp) Total PB
IRV 3,000 mL Saturated: (PB P H2O)FI Pp
FRC 2,500 mL Dry: PB FI Pp
ERV 1,000 mL
VC 4,500 mL (4.05.0 L)
RV 1,500 mL
TLC 6,000 mL (56 L)
Actual values depend on age, sex, height, and race.
2679_APP_A_801-808.indd 803 07/02/13 4:42 PM

DURATION OF FL OW: C OMP R ESSED G A S H U MI D I T Y D E FI C I T S

CYLINDERS
Gas at body temperature and pressure, saturated
Factors: H tank 3.14 Full tank 2,200 psi (BTPS) 37°C
Contains 44 mg/L H2O, 47 mm Hg
E 0.28
psi Factor Absolute mg/L 100
——————— Duration of flow in hours —————————— Relative humidity %
Liter flow 60 Capacity
NOTE: Change before empty! (This may be at 500, 200, 44 mg/L mg/L inspired Humidity deficit
or 100 psi depending on use of cylinder and institutional Minimum 30 mg/L needed for adequate humidity with
policy.) bypassed upper airway
DURATION OF LIQUID C YL IN DER G A S LAW S

344 Liquid wt Boyle’s law: V1 P1 V2 P2 Volume and pressure
——————–— Liquid wt Total wt Empty wt
Flow inversely related,
temperature constant
V1 V2
Charles’ law: Volume and temperature
TOTAL FLOW OF GAS MIX TUR ES T1 T2 directly related, pressure
constant
Oxygen Air/O2 Entrainment P1 P2
Gay-Lussac’s law: – – Pressure and temperature
24% 25:1 T1 T2 directly related, volume
28% 10:1 constant
30% 7:1
V1P1 V2P2
35% 5:1 Combined gas law:
T1 T2
40% 3:1
50% 1.7:1
Poiseuille’s law: fluid flow through tubes
60% 1:1 Pπr4

V̇ 48ln
70% 0.6:1
V̇ flow
Total flow liter flow (air O2 ratio) P pressure
O2 0.79 r radius
Total flow ————— t time
Fio2 0.21 l length
O2 flow (0.21 Air flow) n viscosity constant
Fio2 ———————————— Reynold’s number: 2,000 turbulent flow
Total flow
2,000 laminar flow
LaPlace’s law: surface tension
OXYGEN DE L IVER Y PER C EN TAGES 2T
P –—
r
O2 FLOW RATE OXYGEN
P distending pressure
Cannula T surface tension
1 Lpm 24% r radius of sphere
2 Lpm 28% OHM’s law
Voltage Current Resistance (V IR)
3 Lpm 32%
4 Lpm 36%
5 Lpm 40% AIRWAY CARE
6 Lpm 44%
SUCTIONING
Low-flow system dependent on patient VT ID inner diameter
If patient hyperventilates, Fio2 decreases. Fr French size
If patient hypoventilates, Fio2 increases. (0.5 ID mm 3) 2 Fr
Suction catheter size not to exceed 1⁄2 ID of tracheal tube
HELIUM M IX TUR ES: C ON VER S ION FA C T O R S Suction Pressures
80%/20% use 1.8 Lpm
Adult: 100120 (150 max) mm Hg
70%/30% use 1.6 Lpm
Child: 80100 mm Hg
Infant: 6080 mm Hg
2679_APP_A_801-808.indd 804 07/02/13 4:42 PM

Pediatric ET Tube Size Venous
Age 16 CvO2 [PvO2 0.003 (dissolved)]
————— mm [Hb 1.39 SvO2 (combined)]
4
Length of ET Tube Insertion A-V Difference
Oral Pediatric Amount of oxygen used from each 100 mL of blood per
minute:
Age
12 —— cm C(a v)O2 Cao2 CvO2
2
Normal 46 vol %, 4 vol % indicates decreased O2
Nasal Pediatric
consumption (e.g., hypothermia), 6 vol % indicates
Age increased O2 consumption or decreased tissue perfusion
14 —— cm (e.g., hypotension, sepsis)
3
E S T I MAT I O N O F F I O 2 N E E D E D F O R D E S I R E D
EN DOTR ACHEAL TUBE PLA C E ME N T PaO2
Tip of tube: adult 37 cm above carina, at the level of the Step 1: Calculate a/A.
aortic knob. Typical tube position: oral 2123 cm mark;
nasal 2426 cm mark. a/A ratio Pao2/PAo2
Tracheostomy decreases anatomical dead space by up to 50%. Step 2: Determine desired Pao2.
Endotracheal tubes decrease anatomical dead space by up Step 3: Determine PAo2 to achieve desired Pao2.
to 30%.
Pao2 desired
PAo2 needed —————––
a/A ratio
BLOOD GASES
PAo2 (Paco2 1.25)
Fio2 needed ——————————–
Arterial Venous PB 47
pH: 7.357.45 pH: 7.347.36
PaO2: 80100 mm Hg (100) PvCO2: 3743 (40) mm Hg O X Y G E N AT I O N R AT I O ( P /F )
PaCO2: 3545 mm Hg (40) PvCO2: 4648 mm Hg Pao2
HCO3: 2226 mEq/L Same —–—
%O2
SaO2: 97% SvO2: 70%75% Desired Pao2
Estimated Fio2 needed ————————
Oxygenation ratio
P R EDICTIN G P a O 2 ON R O O M A I R B A S E D O N
AGE (1 484 ) C LA S S I C S H U N T FO R MU L A
Supine: 103.5 (0.42 Age) ± 4 CcO2 Cao2
Seated: 104.2 (0.27 Age) ± 6 Percent shunt ————————–—
CcO2 CvO2 100
Pao2 decreases approximately 1 mm Hg/yr from 80 mm Hg
for ages 6090 yr.
MO D I FI E D E S T I MAT E D SH U N T
ALV EOLAR AIR EQUATION AaDO2/5 on room air
On 100% for every 50 mm Hg approximately 2% shunt
PAo2 [Fio2 (PB PH2O)] (Paco2 1.25)
AaDO2
—–––—
50 2
ALV EOLAR -AR TER IAL OX Y G E N G R A D I E N T
(A-a GRADIEN T)
AaDO2 PAo2 Pao2 H E N D E R S O N -H A S S E LB AC H ( H - H ) E Q U AT I O N
AaDO2 increases 4 mm Hg for every 10 yr of age.
Normal A-a gradient: 20 mm Hg on room air, 50 mm
Hg on 100% O2.
Base
pH 6.1 log ——
Acid [ ] Normal ratio 20:1
OXYGEN C ON TEN T
[
HCO3
6.1 log ——————
Pco2 0.03 ] Log 20 1.3
HCO3 [inv log (pH 6.1)] (Pco2 0.03)

Total O2 content Dissolved Combined
Total CO2 HCO3 (Pco2 0.03)
pH at or below 7.40: for every increase Paco2 20 mm
Arterial Hg pH 0.1 decrease
Cao2 [Pao2 0.003 (dissolved)] pH at or above 7.40: for every decrease Paco2 10 mm
[Hb 1.39 SaO2 (combined)] Hg pH 0.1 increase
2679_APP_A_801-808.indd 805 07/02/13 4:42 PM

M INUTE VEN TIL ATION /C O 2 DIS PARIT Y ME A N A R T E R I A L P R E S S U R E ( MA P )

For every doubling of VE, the CO2 should decrease by 10 mm Normal 60100 mm Hg
Hg. If the CO2 has changed less than this, it most likely
BP systolic 2 (BP diastolic)
indicates increased dead space. ———————————–—
For every decrease of VE by 1/2, the CO2 should increase 3
by 20 mm Hg. If the CO2 has changed more than this,
it most likely indicates increased dead space.
ME A N P U LMO N A R Y A R T E R Y P R E S SU R E
PAP systolic 2 (PAP diastolic)
BASE EXCESS (BE) ————————————––—
3
HCO3 24 BE
DETERM INATION OF BICAR BON ATE N E E D S Y S T E MI C VA S C U LA R R E S I S TA N C E ( S V R )

IN PATIENT S WITH METABOLIC ACID O S I S Right atrial pressure (RAP) 26 mm Hg
Body weight (kg) BD (MAP RAP)
HCO3 needed ————————–—— SVR ——————
4 CO 80
where BD deficit in buffer (base), same number as BE Normal: 9001,400 dynes cm sec5
4 factor that represents the extracellular space
bicarbonate distribution
P U LMO N A R Y VA S C U LA R R E S I S TA N CE ( P V R )
Infuse 1/2 amount IV. Recheck ABGs 5 min. Repeat as neces-
sary only if pH 7.20, BD 10, metabolic acidosis, with (MEAN MAP PCWP)
associated hyperkalemia. PVR ———————–––——
CO 80
Normal: 150250 dynes cm sec5
HEMODYNAMICS
Cardiac output (CO) Stroke volume Heart rate PHARMACOLOGY
Normal 48 Lpm
Central venous pressure (CVP) 08 mm Hg 0.05% 1:2,000
Ejection fraction 65%75% 0.5% solution contains 5 mg/mL 1:200 solution
Right ventricular pressure (RVP) 1525/08 mm Hg 1% solution contains 10 mg/mL 1:100 solution
Stroke volume 4080 mL 2% solution contains 20 mg/mL
Pulmonary artery pressure (PAP) 25/10 mm Hg 3% solution contains 30 mg/mL
Mean PAP 1020 mm Hg mg/mL mL solution mg
30/15 is pulmonary hypertension Actual mg Desired mg
Pulmonary capillary wedge pressure (PCWP) ——––—— —————
mL mL
412 mm Hg
Cross multiply and solve for x.
ESTIM ATED SHUN T EQUATION : Q̇ S /Q̇ T

(PAo2 Pao2 ) 0.003 D R U G D I LU T I O N
————————————————–––——
(Cao2 CvO2 ) [(PAo2 Pao2) 0.003] Volume1 Concentration1 Volume2 Concentration2
V1C1 V2C2
Can use 5 for C(a v)O2 in normal individuals or 3.5 in
critically ill
S TA N D A R D A D U LT D O S A G E S FO R
A E R O S O LI Z E D ME D I C AT I O N S
FICK EQUATION
Racemic epinephrine (Vaponephrin, Micronephrin):
V̇O2 (CO 10) (C(a v)O2)
0.250.5 mL 2.25% solution
Isuprel (isoproterenol): 0.5% 1:200 solution, 0.250.5 mL
CARDIAC IN DEX (CI) Bronkosol (isoetharine): 1:100 1% solution, 0.250.5 mL
Alupent (metaproterenol): 5% solution, 0.3 mL
CO Maxair (pirbuterol): MDI, 0.2 mg/puff, 2 puffs q46h
CI ——
BSA Brethine (terbutaline): MDI, PO, subQ 12 mg of 0.1%
solution
Normal 2.53.5 Lpm/m2
Proventil, Ventolin (albuterol): 2.5 mg (0.5 mL) of 0.5%
solution
STROKE INDEX (SI) Tornalate (bitolterol): MDI liquid 2.25%
Serevent (salmeterol xinafoate): MDI 2 puffs 42 mcg
CI/HR or SV/BSA OD or bid
Normal 3065 mL/m2
2679_APP_A_801-808.indd 806 07/02/13 4:42 PM

Atropine: 12 mg 0.2% or 2% solution; side effects: 0.5 mg, Measured TI and TE should be at least three time constants
dry mouth and skin; 2.0 mg, tachycardia, blurred vision, for complete inspiration and expiration to occur.
pupillary dilation; 5.0 mg, difficulty with speech, Deadspace to tidal volume ratio:
swallowing, urination, mental confusion
Paco2 PEco2
Atrovent (ipratropium bromide): 4080 mcg MDI, 500 mcg VD/VT ——————–—
of 0.02% solution 2.5 mL unit dose Paco2
Mucomyst (acetylcysteine): Normal 0.25 to 0.35, 0.60 ventilatory failure
Two strengths Dead space volume:
20% solution 35 mL tid or qid
10% solution 610 mL tid or qid Paco2 PEco2
Pulmozyme rhDNase or Dornase alpha ——–––———— VT VD mL
Paco2
2.5 mL of 1 mg/mL dose tid
Has no effect on uninfected sputum I:E ratio:
Side effects: voice alteration, pharyngitis, laryngitis, rash, T Total time
chest pain, conjunctivitis f Frequency
Exosurf: 5 kg/mL via ET instillation—half dose given at a I Inspiratory time
time, infant turned to side, then other half given, turned E Expiratory time
to other side; may need to be repeated once or twice in T 60/f
12-hour intervals
Survanta, beractant (modified natural): 4 mL/kg comes in If I known: T I E
8-mL vial already mixed; 25 mg/mL in 0.9% NSS; Given If E known: T E I
1
⁄4 dose at a time, repeat at least 6 hours apart If I and f known:
Intal (cromolyn Na): 20-mg dose qid 20 mg/2 mL 1%
T 60/f
solution
TIE
Pentam (pentamidine): DO NOT mix with bronchodilator,
NSS; recommend 300 mg (1 vial)/6 mL (50 mg/mL) I E
I:E –– : ––
@ 6/pm with Respirgard™ nebulizer I I
Virazole (ribavirin): 6 g/100 mL vial 300 mL H2O T
(20 mg/mL 2%); using SPAG 1218 hr/day 37 days I –——
IE
If V̇E and flow known:
P EDIATR IC DOSAGES
I V̇E Flow rate V̇E
Young’s rule (age 112 yr.): — —– : ———————
E V̇E V̇
Age
Child’s dose ———— Adult dose Flow rate needed:
Age 12
V̇E (IE)
Clark’s rule (infant or child): VT Flow I
Weight in lb
————–— Adult dose Mean airway pressure:
50
FI
Fried’s rule (infant or child up to 2 years): [ ]
—–— (PIP PEEP) PEEP
60
Age in months
—————–— Adult dose V̇E required for desired Paco2 (can substitute for VT also):
150
Current V̇E Paco2
New V̇E —————————
Desired Paco2
PATIENT ASSESSMENT (CRITICAL CARE)
AIR WAY R ESIS TAN CE ES T I MAT E D AUTO-PEEP
PIP peak inspiratory pressure End-expiratory pressure with expiratory hold baseline PEEP
PIP Pl
RAW —––—— cm H2O/L/sec Pl plateau pressure ECG TRACINGS
Flow
Effective dynamic compliance (EDC): Paper speed 25 mm/sec
VT Each small box 0.04 sec
EDC ——–——— L/cmH2O 5 small boxes 1 large box
PIP PEEP
30 large boxes/min
Static compliance (CST): 1,500 small boxes/min
VT Each 1 mm height 1 mV
CST ————— C PR interval 0.12 to 0.20 sec (3 to 5 little boxes)
P1 PEEP
PR 0.20 indicates heart block
Time constant (represents alveolar filling time): QRS width 0.10 sec
If lead I or II has completely negative deflections, check for
RAW CST limb lead placement reversal.
2679_APP_A_801-808.indd 807 07/02/13 4:42 PM

LEAD PLACEMEN T VA LI D I T Y O F S P I R O ME T R Y
I R arm neg/L arm pos/R leg ground Three valid tracings, all of which are free from:
II R arm neg/L leg pos/L arm ground F Cough
III L arm neg/L leg pos/R arm ground F Glottic closure
Augmented—all three into common ground F Baseline error
AVR: right arm ground F Leaks
AVL: left arm ground F Early termination
AVF: left foot ground F Variable effort
F Excessive variability for FVC, FEV1
Standard Bipolar Hookup F Early termination
Plateau is achieved when test is at least 6 sec duration with 0
RA: White
volume change in last second of test.
LA: Black
Minimum paper speed: 20 mm/sec
RL: Green
Excessive variability: 5% or 150mL, whichever is greater
LL: Red
for FVC and FEV1:
C: Brown
Largest value Next largest value
Precordial Lead Placement ———————————————– 100 Percent
Largest value
V1—4th intercostal space R sternal border Extrapolated volume: 5% or 150 mL, whichever is greater
V2—4th intercostal space L sternal border for FVC for that curve
V3—between V2 and V4
V4—midclavicular line 5th intercostal space Percent predicted for FVC, FEV1, FEF25%75%:
V5—anterior axillary line (5th intercostal space) Actual BTPS value
V6—midaxillary line (6th intercostal space) ——————————— 100 Percent
Predicted (race corrected)
ARTIFACT (IN TERF EREN C E WITH N O R MA L

TRACING) R A C E C O R R E C T I O N FO R N O N W H I T ES
1. Muscle tremor: multiple irregular spikes; causes: movement, Predicted value 0.85 Corrected predicted value
tremor; most common type
2. 60-cycle interference; causes: AC electrical equipment, bad C H A N G E S I N S U R V E I LLA N C E S P I R O M E T R Y
ground, broken or damaged wires, wires pulled too tight
3. Wandering baseline; causes: poor contact, poor skin prep, For FVC, FEV1, FEF25%75%:
dried or lost gel, connections not secured, breathing Absolute Largest value Current value mL
4. Isoelectric line; causes: intermittent loss of signal
Largest value – Current value
Percent change ————————————— 100
Largest value
HEART RATE CALCULATION
Expected Change Due to Aging Alone
1. Approximation: Number of QRS/6 sec strip 10
2. Dubin’s method (approximation): Count from R wave on Men
line to next R wave (300, 150, 100, 75, 60, 50, 43) 30 mL in FVC
3. 1,500 divided by number of small boxes between R-R or 25 mL in FEV1
P-P; number of small boxes per minute (30 large boxes in Women
6 sec 5 small boxes in each large box 10 1,500 25 mL in both FVC, FEV1
per 1 minute)—most accurate method
Preshift to Postshift Surveillance
PULMONARY FUNCTION No greater than 200 mL change or 5% in FEV1, FVC
All volumes, flows recorded to 2 decimal places Annual Surveillance

All percentages to 1 decimal place
Labeled with appropriate units No greater than 10% change for FVC, FEV1
ATPS to BTPS No greater change than 5% at any time for FEV1%
For VT, VA, SVC, FVC, FEV1, FEF25%75%
ATPS value Correction factor BTPS value R E LAT E D R E A D I N G
FEV1 Chang, DW: Respiratory Care Calculations. Delmar, Albany, 1994.
FEV1% ——– 100%
FVC
ACCURACY OF SPIROMETERS
Calibrated at least daily
3 L ± 3% or 50 mL, whichever is greater
2679_APP_A_801-808.indd 808 07/02/13 4:42 PM

APPENDIX Common
Performance
Elements
EQUIPMENT AND PATIENT ASSESSMENT AND IMPLEMENTATION

PREPARATION 9. Positions the patient for the procedure
1. Verifies, interprets, and evaluates physician’s order or 10. Assesses the patient including, where applicable, vital
protocol signs, Spo2, breath sounds, and ventilatory status
2. Scans chart for any other pertinent data and notes, includ-
ing diagnosis, medications, therapies, radiographic, and
other laboratory results
FOLLOW-UP
3. Washes hands or applies disinfectant 11. Reassesses and reinstructs the patient as needed
4. Selects, obtains, assembles equipment correctly, verifies 12. Ensures patient comfort and safety
function 13. Maintains/processes equipment
5. Troubleshoots equipment and corrects malfunctions if 14. Disposes of infectious waste and washes hands or
indicated applies disinfectant
6. Applies personal protective equipment (PPE); observes 15. Records pertinent data in chart and departmental
standard precautions and transmission-based isolation records
procedures as appropriate 16. Notifies the appropriate personnel and makes any
7. Identifies the patient, introduces self and department necessary recommendations or modifications to the
8. Explains the purpose of the procedure and confirms patient care plan
patient understanding
809
2679_APP_B_809-810.indd 809 07/02/13 4:42 PM

2679_APP_B_809-810.indd 810 07/02/13 4:42 PM
Glossary
abduction: movement away from the axis of the body anesthesia: loss of feeling or sensation
abruptio placentae: sudden separation of the placenta from the angiocath: short for angiocatheter; it is the catheter inserted into a
uterine wall vein to gain intravenous access
accuracy: the correct value; errorless anhydrous: without water; dry
acid: a substance that yields hydrogen ions or protons to another anion: negatively charged atom
substance anomaly: any deviation from what is regarded as normal
acidosis: an abnormal state of increased hydrogen ion in the blood anoxia: without oxygen; antiquated term for hypoxia
acrocyanosis: symmetric mottled cyanosis of hands and feet antagonist: a drug having affinity but no efficacy; blocks, inhibits,
actuator: a device to initiate an action or process or reverses effect
acute: sudden onset, short course, severe antecubital (fossa): the triangular area in the bend of the elbow
additive: two drugs in combination; effects equal the algebraic sum anterior: the front of a structure
of each contribution anticholinergic: synonym for parasympatholytic
adduction: movement toward the midline of the body anticoagulant: a substance, such as heparin or warfarin, used to
adenopathy: any enlargement of a gland, especially lymphatic tissue increase the clotting time of blood
adhesion: the molecular force exerted between two surfaces in contact antihistamine: an agent that counteracts the effect of histamine, a chem-
adjunctive: assisting or aiding; auxiliary ical agent believed to cause hypersensitive or allergic symptoms
adrenergic: stimulating epinephrine receptors (sympathomimetic) antiseptic: a chemical agent that interferes with infectious potential;
adventitious: foreign, acquired; occurring in unusual or abnormal places usually applied to the human body
adverse: unfavorable or bringing harm antitussive: a cough suppressant
aerobe: organisms requiring oxygen for metabolism Apgar score: an evaluation of an infant’s physical condition; usually
aerosol: liquid or dry particles suspended in gas performed at 1 minute and again 5 minutes after birth
AFB: acid-fast bacillus; a bacterium that accepts a carbol-fuschin apical: pertaining to the pointed part of an organ (apex)
stain, and, after an application of an acid alcohol, a counter apices: the uppermost portions of an organ, as in the apices of the
stain of methylene blue; also known as the Ziehl-Neelsen test; an lungs; singular is apex
example of an acid-fast organism is mycobacterium tuberculosis apnea: the cessation of breathing
affinity: having attraction to arrhythmia: an abnormal heartbeat pattern on ECG
agonist: having affinity and efficacy; producing the desired affect arteriosclerosis: the hardening of the arteries; loss of elasticity of the
air bronchogram: the outline of an airway as seen on a chest x-ray; artery walls
the air-filled tube is outlined against the consolidated lung paren- artifact: an artificial or extraneous characteristic introduced by accident
chyma; seen chiefly in pneumonia artificial intelligence system: A computer system able to analyze,
airway resistance: the resistance to airflow as a result of the narrow- problem solve, and make decisions similar to the human brain
ing of an airway asepsis: the exclusion of pathogenic microorganisms
algorithm: A step-by-step process by which a procedure should be aseptic: free from infection or infectious matter
performed. aspiration: the act of sucking up or sucking in, such as inhaling a
alkalosis: an abnormal state characterized by a decrease in blood foreign body or vomitus; withdrawing fluids from a body cavity
hydrogen levels (e.g., suctioning)
alleviating: relieving; used to describe conditions that might relieve assisted breath: a ventilator delivered breath at the set tidal volume
a symptom given in response to an inspiratory effort
ambient: atmospheric; surrounding asterixis: a tremor characterized by the flapping of the hand; usually
ambulatory: able to walk; not confined to bed rest seen in liver disease
American Standard Safety System (ASSS): the connection between the asymmetrical: a lack of similarity or correspondence of parts on each
outlet of a large medical gas cylinder and the pressure-reducing side of an organism
valve asynchrony: not occurring simultaneously. Used to describe when a
amniotic fluid: the fluid in the sac surrounding the developing embryo patient is not breathing with the ventilator.
amplitude: fullness, breadth, range, or extent ataxia: the uncoordination of voluntary muscular action, particu-
anaerobe: organism that does not use oxygen for metabolism larly related to walking or reaching
anaphylaxis: severe allergic hypersensitivity; may result in shock, atelectasis: the collapse of the alveoli (air sacs in the lungs)
airway obstruction atherosclerosis: the buildup of fatty deposits or plaque within a vessel
anastomosis: intercommunication (natural or surgical) of blood atmospheric temperature and pressure, saturated (ATPS): the condi-
vessels or other hollow organs or parts tion of exhaled air once breathed into a measuring device
anatomic dead space: part of the tracheobronchial tree where there atomizer: hand bulb device to produce large-particle spray
is ventilation without perfusion; the entire conducting airway atopic: a hereditary allergic state
anemia: deficiency or decrease in amount of red blood cells or he- atrium: the upper chamber; connected to several other chambers or
moglobin passageways
aneroid: mechanical gauge, working without a fluid atrophy: the wasting away of an organ (e.g., muscle)
811
2679_Glossary_811-820.indd 811 07/02/13 4:49 PM

812 • GLOSS ARY
augment: to exacerbate or increase; supplement capnometer: a device used to detect the presence of carbon dioxide
auscultation: listening for sounds produced in the body in exhaled air
autoclave: a device utilizing increased pressure and temperature in capnometry: the numerical measurement of exhaled carbon dioxide
order to achieve sterilization pressure
autofluorescence: the ability of a structure to emit light cardiac index: a standardized measure of cardiac performance; the
auxiliary: functioning as secondary, supplemental volume per minute of cardiac output per square meter of body
surface area; the normal resting average is 2.2 L
bacteremia: the presence of bacteria in the blood cardiac output: the total amount of blood pumped per minute; heart
bactericidal: an agent that kills or destroys bacteria rate multiplied by stroke volume
bacteriostatic: an agent that prevents growth and development of cardiomegaly: an enlarged heart
bacteria cardioversion: the application of direct current (at a lower wattage
baffle: a surface in a nebulizer designed to impact large aerosol par- than defibrillation) to reverse abnormal rhythm (usually PAT)
ticles and reduce their size and resume normal sinus rhythm
barotrauma: a physical injury sustained as a result of exposure to caseation (caseous): a collection of cheeselike material from coagula-
ambient pressures above normal tion necrosis of tissue, especially in tuberculosis
base: alkaline, yields hydroxyl ions; combines with acid to form salt catecholamine: natural or synthetic chemicals similar in structure to
basilar: pertaining to the bases or widest part of pyramid-shaped organ epinephrine and norepinephrine
␤ agonist: a drug that activates the beta sympathetic receptors catheter: a hollow tubular instrument for the passage of fluid from
(lungs, cardiac) or into a body cavity
bevel: an angled tip cation: a positive ion
bifurcation: division into two branches caudad: toward the tail
bilateral: on two sides cell mediated: physiological mechanisms occurring by way of spe-
binaural: relating to both ears cific cells (as opposed to neurological or humoral)
biohazard: anything that poses a risk to a living organism such as Centers for Medicare and Medicaid Services (CMS): the federal
infected bodily fluids or infectious agents agency that administers Medicare and Medicaid including chil-
biohazard containers: special containers used for the disposal of dren’s services
equipment or supplies that are contaminated with biohazardous central venous pressure: the measurement of the blood pressure rep-
materials resenting the filling pressure of the right atrium
Biot’s respiration: an irregular, chaotic breathing pattern with peri- cephalad: toward the head
ods of apnea associated with certain diseases Certificate of Medical Necessity (CMN): documentation required
BiPAPTM unit: a machine used to deliver bilevel positive airway pressure by insurance companies (specifically Medicare) attesting to the
bite block: an instrument inserted into the mouth used to prevent the medical need of a particular piece of equipment or treatment mo-
patient from biting down on the tongue or an artificial airway dality such as oxygen therapy
blanching: loss of color; becoming pale cesarean: a surgical procedure through an abdominal wall incision
bland: gentle, not irritating or stimulating; mild or soothing for delivery of a fetus
bleb: blister; air cyst adjacent to the pleura chest wiggle: the shaking of the chest as observed during high-
body surface area (BSA): a mathematical calculation of the total frequency ventilation in neonates; this observation is one of
physical volume the body comprises in space the criteria used to assess the adequacy of high-frequency
body temperature and pressure, saturated (BTPS): the condition of ventilation
air in the lungs Cheyne-Stokes respiration: a regularly irregular increase and decrease
boiling point: the temperature at which a liquid turns to a gaseous in depth of breathing with periods of apnea
form choanal atresia: the abnormal closure of the normal opening of the
bradycardia: a slow heart rate less than 60 bpm in an adult posterior nares; failure to develop in utero
breech: fetus positioned feet down cholinergic: produces the effect of acetylcholine (parasympathomimetic)
bronchoactive: any drug affecting the tracheobronchial tree chorionic villi: numerous branching projections from the surface of
bronchoconstriction: narrowing or spasm of the smooth bronchial the outermost layer of the fetal membranes
muscle lining the airways chronic: persisting for a long time; slow progression
bronchodilation: widening or relaxation of bronchial smooth muscle chronotropic: affecting time or rate
bronchophony: an increase in transmitted sound in the lung due to chylothorax: the presence of milky lymph fluid in the pleural space
increased density of lung tissue such as consolidation circumoral: occurring around or surrounding the lips
bronchorrhea: excess mucus production from the lung closed-loop control: A self-adjusting control system.
bronchoscope: a device, either rigid or flexible fiber optic, inserted clubbing: a painless enlargement of the distal phalanges associated
into the tracheobronchial tree used to visualize the airways and with chronic hypoxia
to obtain tissue, mucus, or cell-washing samples for biopsy or coagulation: blood clotting
other laboratory testing coagulopathy: an abnormal clotting of the blood
bronchoscopy (AFB): a medical procedure in which an instrument cold stress: the phenomenon of increased oxygen consumption when
called a bronchoscope is introduced into the tracheobronchial tree exposing the face of a newborn to cold air
in order to visualize the airways, obtain tissue samples (biopsy), or collateral: accessory or secondary
to aspirate secretions and alleviate a blocked airway collection chamber: a section of a chest drainage system that collects
bronchospasm: same as bronchoconstriction the pleural fluid
buffer: substance that prevents extreme swings in pH colloid: homogeneous material of gluelike consistency; aggregate of
bulla: thin-walled, air-filled area surrounded by normal tissue more molecules evenly dispersed in solution resisting sedimentation;
than 1 cm in diameter cannot pass through a semipermeable membrane
colonization: organisms growing in a host where they are not normally
cachectic: characterized by severe generalized weakness, malnutri- found without invasion of tissue or toxic effects; contamination
tion, emaciation; wasted appearance with poor skin turgor colorimetric: relating to a procedure for quantitative chemical analy-
cachexia: condition of general ill health and malnutrition character- sis based on a comparison of color to a standard
ized by weakness and emaciation combustible: rapid oxidation of substance accompanied by the pro-
calibration: determining the accuracy of an instrument duction of heat and light; burning
calorie: a heat energy unit; the quantity of heat required to raise 1 commensalism: relationship in which an organism uses the host with-
gram of water 1⬚ centigrade out harm or benefit; always capable of being potential pathogens
capnography: measuring and recording a graphic display of exhaled communication: the meaningful exchange of information
carbon dioxide as a waveform compensation: counterbalancing
2679_Glossary_811-820.indd 812 07/02/13 4:49 PM

| GLOS S ARY • 813
compensatory: counterbalancing a lack or defect in body physiologi- Diameter Index Safety System (DISS): a safety system connection
cal function between a small high-pressure cylinder and the reducing valve
compliance: volume/unit pressure; ability to expand diaphoresis: profuse sweating; cold and clammy
compressibility factor: a numeric constant for any given ventilator diaphragmatic hernia: a protrusion of the intestines through the dia-
and circuit representing the amount of gas that will be lost in the phragm and into the lung space
circuit due to pressure increasing the density of the gas diastole: the relation of the heart between contractions when filling
compressible volume: the amount of gas that will be lost in the cir- occurs
cuit due to pressure increasing the density of the gas diastolic pressure: the pressure in the heart and blood vessels during
computer-directed weaning: weaning from mechanical ventilation relaxation of the heart
based on computer analysis of patient data diffusion: the movement of molecules from an area of higher concen-
condensate: changing of gas to liquid tration or pressure to an area of lower concentration or pressure
consolidation: becoming solid; airless lung tissue diluent: making more watery; a substance used to dilute
continuous mandatory ventilation: a ventilator mode in which the disinfectant: a chemical that kills vegetative cells; usually applied to
ventilator delivers a set tidal volume or minute ventilation at a equipment
determined respiratory rate disinfection: the act of destroying pathogenic microorganisms (but
continuous spontaneous ventilation: patient breathing independent does not sterilize), usually by chemical means
from the ventilator dispersal agent: a chemical added to a pharmaceutical prepara-
contraindication: any treatment that is inadvisable or improper; a tion to ensure the even distribution of the drug throughout the
treatment that should not be done product
contralateral: on the opposite side displacement: removal from the normal position or location
copious: a large amount distal: the farthest point away from the point of origin
costophrenic: the angle between the rib cage and diaphragm diuretic: a drug or chemical that increases the formation and release
couplant: the lower chamber of an ultrasonic nebulizer; the upper of urine
chamber contains the medication solution separated from the dressing: a clean or sterile covering applied over a wound
couplant by a diaphragm; the couplant contains fluid to transmit drugs: chemical substances that when taken into a living organism
the piezoelectric vibrations to the diaphragm alter its function or processes
CPAP unit: a device that delivers continuous positive airway pressure ductus arteriosus: a fetal vessel connecting the left pulmonary artery
crackles (coarse): a harsh, discontinuous adventitious sound heard to the descending aorta, creating a shunt
during auscultation caused by fluid or mucus in the larger air- ductus venosus: a fetal connection of the left umbilical vein through
ways; the obsolete term is rale the liver to the vena cava
crackles (fine): a discontinuous adventitious sound heard during dynamic: characterized by energy or force; moving and changing
auscultation caused by fluid in the smaller airways; the obsolete dyskinesia: abnormal or difficult movement
term is rale dysphagia: difficulty swallowing
crepitation: a crackling noise or sensation dysphasia: difficulty in speaking or in understanding language
crepitus: a crackling noise or sensation dysphonia: impairment of the voice
critical pressure: the pressure exerted by a gas in an evacuated con- dysplasia: abnormal tissue growth
tainer at its critical temperature dyspnea: a subjective feeling of shortness of breath; difficulty breathing
critical temperature: the highest temperature at which a substance dysrhythmia: an abnormal heart rhythm; arrhythmia
can exist as a liquid regardless of pressure dystocia: difficult childbirth
crystalloid: a substance that, when in solution, can pass through a
semipermeable membrane ecchymosis: “black and blue”; bruising or purplish patch caused by
cuirass: breastplate or chest piece of a negative pressure ventilator extravasation of blood into the subcutaneous tissues
cultural diversity: the vast array of behaviors, including health care, eclampsia: the sudden development of convulsions associated with
attributed to the different peoples and cultures found in society late-stage pregnancy associated with hypertension, proteinuria,
cumulation: an increasing amount in the body when the rate of re- and edema
moval or inactivation is slower than the rate of administration edema: an abnormal increase of fluid in the intercellular spaces of
cyanosis: a bluish color of the skin and mucous membranes associ- the body; swelling
ated with hypoxia; requires 5 g of deoxygenated hemoglobin efficacy: usefulness, having the desired effect
egophony: a modification of the transmission of the voice heard
dead space: ventilation without or in excess of perfusion; high- through the stethoscope over areas of lung consolidation; a bleat-
ventilation/perfusion (V/Q) relationship; rebreathed air ing quality
debilitated: a weakened condition elastance: the tendency to recoil or collapse after stretching; the
decannulation: the removal of a tracheostomy tube opposite of compliance
decongestant: an agent that reduces swelling or edema of mucous electrolyte: a substance that in solution can conduct electrical charge
membranes embolism: an obstruction of a blood vessel by foreign matter (blood
decontamination: the initial cleaning of an object or person to make clot, fat, air) that travels from another area
it safe to handle by unprotected personnel emesis: the act of vomiting
decubitus (position): horizontal posture empathetic: feeling the emotional or physical state of another while
decubitus (ulcer): an ulcer caused by prolonged unrelieved pressure remaining objective and separate
on a bony prominence empathy: the ability to share and relate to the difficulties, emotional
defibrillation: an electric shock applied to the heart to reverse fibril- and physical, of another while remaining objective
lation and resume a normal rhythm empyema: the accumulation of pus or infected fluid in the pleural
dehydration: the removal or deprivation of water space
demographics: statistical study of groups of people endemic: present among particular people in a specific locality
density: mass per unit volume; closeness or compactness endocytosis: the process by which a cell takes in material from its
denudation: the act of stripping or laying bare; remove covering environment; bulk transport by enclosing in a membrane
depolarization: the reduction of ion distribution differentials across endotoxin: a substance found in bacterial cell walls, especially gram-
a polarized semipermeable membrane usually resulting in nerve negative bacteria, associated with various physiological effects,
conduction or muscle contraction including fever and shock
deposition: the collection of matter in any part enteric: pertaining to the gastrointestinal tract
desiccation: depriving a substance of moisture; to dry out entrainment: to carry along, as when air is pulled into the flow of a
diagnosis: the art of determining the nature of a patient’s disease; a gas due to shearing forces
conclusion reached enzyme: complex proteins that act as catalysts in chemical reactions
2679_Glossary_811-820.indd 813 07/02/13 4:49 PM

814 • GLOSS ARY
EPAP: expiratory positive airway pressure; the amount of positive gestation: the duration of pregnancy
airway pressure above ambient applied to the expiratory phase glutaraldehyde: a cold sterilization agent
of a breath granuloma: an epithelial tissue formed by chronic inflammation;
epidemic: an extensive outbreak or unusually high incidence at cer- tumorlike pathological structure composed of macrophages and
tain times or places lymphocytes resulting from inflammation; disordered repair
epidemiology: the study of the distribution and spread of disease gravida: a pregnant woman
epistaxis: a nosebleed
epithelium: the covering of internal or external organs or vessels hazardous material: any substance that has the potential to cause
erosion: wearing away of a surface harm
erythema: redness of the skin from blushing or inflammation hematocrit: the percentage of blood that is cells compared to liquid
etiology: the study of the causes and sources of disease plasma
eukaryotic: pertaining to cells with a true nucleus, nuclear mem- hematoma: a localized collection of extravascular blood
brane, and capable of mitosis hemochromatosis: a rare blood disorder characterized by the deposi-
eupnea: normal breathing tion of iron in bodily tissues
evaporation: a change from liquid to gaseous form occurring below hemoglobin: a protein in red blood cells that transports oxygen
its boiling point hemolysis: the rupture of red blood cells
exacerbation: an increase in the intensity or seriousness of an existing hemolytic: capable of rupturing red blood cells
disease hemoptysis: coughing up blood
excretion: the process of elimination as in waste matter or normal hemorrhage: excessive bleeding
discharge hemothorax: the collection of blood in the pleural cavity
exotoxin: a toxin excreted into the environment by living organisms Hertz (Hz): a measurement of wave frequency; 1 Hz is equal to
expectoration: coughing up and spitting out of sputum 1 cycle per second (cps)
exsanguination: the extensive loss of blood due to hemorrhage high-frequency ventilator: a mechanical ventilator that utilizes vari-
extrapolation: to infer unknown data from known data ous technologies in order to deliver small volumes and respira-
extrathoracic: outside of the chest cavity tory rates greater than 60 breaths/min
extubation: the removal of a tube holding chamber: an auxiliary device for the delivery of a broncho-
exudate: a fluid with a high protein content, resulting from abnor- active drug with a metered-dose inhaler; its function is to increase
mal capillary leakage or inflammation the amount of drug delivered to the lung and minimize impaction
of the drug in the oropharynx
facilitate: to enhance or make easy homeostasis: remaining relatively constant even when the environ-
facultative: not obligatory; having the ability to adapt to changing ment is changing
conditions homogeneous: a uniform character and consistency
fasciculation: small localized muscle tremors visible under the skin hormone: a substance originating in an organ or gland and transported
fastidious: having very specific requirements; “picky” by the bloodstream to other areas where it has a regulatory effect
febrile: body temperature greater than 100.4⬚F humoral: pertaining to physiological mechanisms in body fluids by
fenestrated: having an opening, similar to a window way of chemical or biological mediators (as opposed to neuro-
fetal asphyxia: suffocation of the fetus in the uterus caused by inter- logical or cell mediated)
ruption of its blood supply Hx: an abbreviation for history; as in “the patient has a Hx of COPD”
fetid: foul smelling; putrid hydration: the absorption of water
fibrillation: uncoordinated muscular twitching; abnormal, chaotic, hygrometer: an instrument for measuring atmospheric moisture
irregular impulses from multiple foci hygroscopic: absorbing moisture
fissure: a deep furrow or slit hyperbilirubinemia: an excess of bilirubin in the blood as a result of
fistula: any tubelike passage between two organs liver dysfunction or destruction of red blood cells
flaccid: weak or soft muscles, limp hypercapnia: excess carbon dioxide in the blood greater than
flail: a paradoxical motion 45 mm Hg
flammable: tending to ignite or burn easily hypercarbia: hypercapnia
flange: a projecting edge or rim hyperextend: to stretch out maximally
flaring: to open, spread outward hyperextension: the movement of stretching or straightening of a
flexible bronchoscope: a bronchoscope that utilizes the principle of limb or part beyond the normal limit
fiber optics in order to visualize the tracheobronchial tree; it is hyperinflation: overdistention with air
smaller than a rigid bronchoscope hyperlucent: excess radiolucency; dark or black on x-ray
flip-flop phenomenon: a paradoxical decrease in the blood oxygen level hyperoxia: excess oxygen supply
when returning to a higher Fio2 after an initial decrease in Fio2 hyperpnea: an increase in the depth of breathing
flow: an expression of units of volume versus time hyperresonant: an increase in vibration sound created by percussion on
flow rate: volume per unit time; the speed of movement of a fluid a body cavity or part, usually indicating a more air-filled condition
through a tube hypersensitivity: the increased threshold of response to irritating
flush: to wash out stimuli
fomite: nonliving material that may transmit infectious agents (e.g., hypertension: high blood pressure, greater than 150/90 mm Hg in
bed linens, equipment) an adult
foramen ovale: a perforation or opening through the septum hyperthermia: elevated body temperature
between the right and left atria as part of fetal circulation hypertonic: having a greater osmotic pressure; concentration of the
forced expiratory technique (FET): a breathing maneuver designed solute is higher, causing water to move across a semipermeable
to enhance the expectoration of sputum membrane toward the hypertonic solution in an attempt to dilute
Fowler’s position: sitting upright, head elevated the solution
fractional distillation: the process of successively separating the com- hypertrophy: the enlargement of a tissue or organ (e.g., muscle)
ponents of air to manufacture oxygen hyperventilation: alveolar air exchange in excess of that needed for
frangible: breakable or fragile metabolic needs; signified by a Pco2 less than 35 mm Hg in arte-
fremitus: palpable vibrations rial blood
fusible: capable of being melted hypervolemia: an increase in blood volume
hypocapnia: decreased carbon dioxide in the blood
gain: a control to increase a value of an electronic device hypoglycemia: low blood sugar
galvanic: creating steady direct current hypopnea: the decreased depth of breathing
2679_Glossary_811-820.indd 814 07/02/13 4:49 PM

hypostasis: stagnant blood flow in a dependent part of the body intravenous tubing: the tubing used to connect the intravenous cath-
hypotension: low blood pressure; less than 100/60 mm Hg in an eter to the intravenous solution during intravenous therapy
adult intrinsic: a natural or integral part of something
hypothermia: low body temperature invasive: used to describe spread or intrusion; for example, an inva-
hypotonic: a decreased concentration of solute with lower osmotic sive procedure would be one that requires intrusion into the body
pressure than the solution with which it is compared inverse: inside out or opposite
hypoventilation: an alveolar air exchange less than required to meet iodophor: iodine-based disinfectant
metabolic needs, as signified by an arterial Paco2 greater than ionization: dissociation of a substance in solution into ions
45 mm Hg IPAP: inspiratory positive airway pressure; the amount of positive
hypovolemia: reduced blood volume airway pressure above ambient applied to the inspiratory phase
hypoxemia: insufficient oxygen in the blood; PO2 less than 80 mm Hg of a breath
hypoxia: insufficient oxygenation to the tissues irrigation: washing out of a wound or body cavity with fluid
hysteresis: a phenomenon in which two related phenomena fail to ischemia: the localized reduction of perfusion to a part or organ
keep pace with each other (e.g., compliance of the lung during isoelectric: the baseline on an ECG rhythm strip
inspiration and expiration) isotonic: containing equal concentration of solute to body fluids, 0.9%
I:E ratio: an expression used to compare the length of expiration to jaundice: yellow coloration of tissues
the length of inspiration; for example, an I:E ratio of 1:3 means jet: a narrowing in a tube creating a rapid stream of fluid
that expiration is three times longer than inspiration; it is not a
time measurement Kussmaul’s respiration: extreme hyperventilation associated with
iatrogenic: physician induced, usually referring to an adverse effect diabetic acidosis
idiopathic: of unknown cause or origin kymograph: a rotating drum for recording variations or undulations
idiosyncrasy: a patient’s individual reaction or hypersensitivity to kyphosis: an abnormal increase in curvature of the spine with back-
a drug ward convexity
immunology: the study of the defense mechanisms by which the
body wards off diseases (the immune system) laceration: a tearing wound
immunosuppressed: reducing the host’s ability to defend against infec- laminar: consisting of layers
tion, such as from disease or medications lancet: small, pointed, two-edged surgical puncturing device
immunosuppression: a reduced ability of the immune system to re- lanugo: soft, fluffy hair on a fetus
spond; may be purposefully induced by medication laryngospasm: constriction of the laryngeal muscles
impaction: a condition of being tightly wedged or retained in a part; latent: not manifest; dormant; potential
stuck lateral: pertaining to the side or away from the midline
incisors: the four upper and lower front teeth latex: sap produced in certain plants used to make rubber
indication: a sign or circumstance that points to a particular diag- lavage: washing out of an organ or cavity as in the lungs, stomach,
nosis or treatment intestines
induction: causing something to occur lecithin/sphingomyelin (L/S) ratio: test compares the measurement
infarction: the formation of an area of necrosis as a result of loss of of the two substances to determine fetal lung maturity
blood supply lesion: a broad term indicating any injury or loss of function to body
infection: the introduction of pathogenic organisms into a host, tissue
where they may thrive to a point of disruption of homeostasis lethargic: sleepy
inferior: below; bottom portion leukotriene: a chemical mediator of immediate inflammation
infiltrate: to penetrate the interstices of a tissue lobe: a distinct division or portion of an organ
infiltration (infiltrates): radiodense accumulation in a tissue lobule: a smaller division of an organ or subdivision of a lobe
infrared absorption: the amount of electromagnetic radiation of a logarithm: the exponent value indicating the power to which a fixed
wavelength greater than that of the red end of the spectrum pen- number must be raised
etrating a substance; can be used to measure the amount of the loops: a system in which data is used to determine needed changes.
substance present They may be open or closed
inhibition: checking or restraining the action of organ, cell, or chemical lordosis: the forward curvature of the spine
inotropic: affecting the force of muscle contraction lordotic: positioned with the spine curved forward
insidious: coming on gradually or almost imperceptibly lubricant: a substance used to make a surface slippery, thus reduc-
inspissated: thickened or dried by fluid evaporation as in secretions ing friction; water-soluble lubricants are used in medicine to ease
instillation: the direct administration of a liquid by drops insertion of a device, thereby reducing trauma to mucous mem-
insufflation: blowing a gas into a body cavity branes due to friction; this is best exhibited by the application of
interaction: the process of acting on each other a water-soluble lubricant as in orotracheal intubation
interface: a device used to connect a patient to a particular piece of Luer-LokTM: a locking mechanism to secure a syringe in place, usu-
equipment ally by twisting
intermittent mandatory ventilation: a ventilator mode in which the lumen: the channel within a tube
ventilator delivers a set number of breaths at the prescribed tidal lymphadenopathy: disease and enlargement of lymph nodes
volume, but the patient is permitted to breath spontaneously in lymphedema: the accumulation of lymphatic fluid in soft issues re-
between the ventilator delivered breaths sulting in swelling
intersection: a site at which one structure crosses another
interstitium: situated between parts of a tissue; extracellular space malacia: an abnormal softening
intracranial pressure (ICP): pressure of the subarachnoid fluid in the malaise: a generalized feeling of illness or discomfort
sac between the skull and the brain Mallampati classification: a rating system based on the anatomy and
intraflow: a device in the path of flow of a fluid system to control soft tissue appearance of the oropharynx; it is used to evaluate
the flow the difficulty of orotracheal intubation
intrapulmonic percussion ventilation (IPV): a device that uses pulsatile mandatory breath: a required ventilator delivered breath that
vibrations at varying amplitudes in order to mobilize secretions mandible: the lower jaw
intravenous catheter: a small device inserted into a vein in order to meatus: an opening or tunnel through a body part
establish venous access mechanical dead space: an artificial adjunct or extension to the con-
intravenous solution: the solution administered directly into a vein ducting airway where ventilation exists without perfusion and
during intravenous therapy gas exchange
2679_Glossary_811-820.indd 815 07/02/13 4:49 PM

816 • GLOSS ARY
meconium: first fetal fecal matter orthostatic: related to or caused by body position
medial: pertaining to the midline OSHA: Occupational Safety and Health Administration; an agency
melting point: temperature at which a substance changes from a of the federal government that oversees and regulates workplace
solid to a liquid safety and employee health
metabolism: the sum of all physical and chemical changes that take osmosis: the movement of fluid across a semipermeable membrane
place within an organism to a greater solute concentration
metabolite: any product of metabolism osteoporosis: a decrease in the mass-to-volume ratio of mineralized
metastasis: the process of tumor cells spreading to distant parts of bone
the body otitis media: inflammation or infection of the middle ear
miliary: lesions resembling millet seeds as in tuberculosis oxygen concentrator: a device that extracts high concentrations of
monitoring: the continuous observation or collection of data oxygen from room air
morbidity: the state of being ill oxygen-conserving devices: oxygen delivery devices that attempt to
Moro reflex: a normal reflex in an infant elicited by a sudden loud noise limit the waste of oxygen during use
morphology: the study of the shape and structure of organisms
mortality: the number of deaths per unit population in a specific group palliative: relieves or soothes symptoms without a cure
MSDS sheet: Manufacturer’s Safety Data Sheet; this sheet contains pallor: paleness of the skin
all of the safety information regarding a chemical, including palpation: examination by means of the hands
exposure and toxicity information para: a woman who has given birth to an infant; denoted by a nu-
mucoid: resembling mucus; clear white secretions merical prefix for each occurrence
mucokinetic: the movement of mucus paradoxical respiration: a type of breathing in which part of the
mucolytic: the breaking down of mucus lung deflates during inspiration and expands during expiration; a
mucopurulent: containing mucus and pus respiration that is the opposite of expected
multifocal: originating from multiple points paralysis: a loss of power of voluntary movement through injury or
muscarinic: the stimulation of parasympathetic neuroeffector sites; disease
includes increased mucous and salivary gland discharge, decreased paramagnetic: a substance that is in the same direction in an induced
heart rate, vasodilation, hypotension magnetic field as the magnetizing field
mutualism: a mutually beneficial relationship parameters: a set of limits or guidelines
mycology: the study of fungi parasitism: organisms having a harmful relationship to the host
myelitis: the inflammation of the spinal cord with associated motor parasympatholytic: antagonist to parasympathetic system (anti-
or sensory dysfunction cholinergic)
myocardial infarction: a blockage of a coronary blood vessel leading parasympathomimetic: mimics the effects of the parasympathetic
to death of heart muscle; heart attack system
myopathy: disease of muscle parenchyma: the functional tissue of an organ (as opposed to sup-
porting structures)
naris: the opening to the nose; the nostril; plural is nares parenteral: denoting any route other than the gastrointestinal tract
nasal continuous positive airway pressure (NCPAP): continuous paresis: partial or incomplete paralysis; muscle weakness
positive airway pressure applied to the nose paresthesia: a tingling sensation in the extremities; “pins and needles”
nasal mask: a noninvasive ventilation interface that covers only the paroxysmal (cough): a sudden attack, often violent in nature
nose particulate: in the form of fine particles, very small piece or portion
nasal pillows: a noninvasive ventilation interface that has two of solid or liquid
prongs that fit into the nostrils pasteurization: a disinfection technique using increased temperature
nebulizer: a device that produces aerosol (fine spray or mist) pow- for a specific period of time
ered by an external gas source (air or oxygen) patency: a condition of being wide open and unblocked
necrosis: the death of cell or tissue pathogen: a disease-producing organism
needle: a pointed sharp implement used for injection or the puncture pathology: study of abnormal structure
of an anatomical structure such as an artery or vein pathophysiology: the study of mechanisms of disordered function
neonate: a newborn infant pectoriloquy: the increased transmission of vocal sound through
neoplasm: the new growth of abnormal tissue consolidated lung tissue
neutral thermal environment: an environment created to maintain pectus carinatum: a condition of an abnormally protruding sternum;
the normal body temperature of an infant to minimize oxygen pigeon breast
consumption and caloric expenditure pectus excavatum: a condition of an abnormally concave sternum;
nicotinic: the stimulation of acetylcholine ganglionic (sympathetic funnel chest
and parasympathetic) sites and skeletal muscle receptors; pro- penetration: the process or capacity of entering within a part
duces increased blood pressure, vasoconstriction, heart rate percussion: a diagnostic technique of manually striking on a body
nodule: a small, round mass or lesion part, using short, sharp blows, to produce a sound in order to de-
nomogram: the graphic representation of normal values termine the size, position, or density of the underlying structures
noninvasive positive pressure ventilation (NPPV): mechanical venti- perforate: to pierce through and make a hole
lation not requiring intubation or tracheostomy perforation: A hole made by piercing through a structure such as an
nosocomial: hospital acquired; an infection that develops in the hospital artery or vein
perfusion: the passage of a fluid through the body (usually blood)
obligate: able to live only in the way specified periodic breathing: an irregular breathing pattern with recurring
obtunded: insensitive to pain or other stimuli due to a decreased intervals of apnea common in premature infants
level of consciousness permeability: the state of permitting passage of a substance
obturator: a removable device used to plug a tube during insertion phagocytosis: the process by which a cell “eats” by engulfing par-
oligohydramnios: an abnormally small amount of amniotic fluid ticles; a type of endocytosis
opacification: less able to transmit light; increased density on x-ray phalanges: (plural of phalanx) digits; any bone of the fingers or toes
opportunistic: commensal organisms that become pathogens when a pharmaceutical: the study or phase of drugs including dosage, prepa-
proper route of entry is available ration, dispensation, and routes of administration
optimum: most favorable; ideal or best pharmacodynamics: the study of drug mechanisms, actions, effects,
oronasal mask: A mask that covers both the nose and the mouth. and side effects
Used as a BiPAP interface. pharmacognosy: the branch of pharmacology studying natural drugs
orthopnea: the ability to breath easily only in the upright position and their constituents and sources
2679_Glossary_811-820.indd 816 07/02/13 4:49 PM

pharmacokinetics: the study of absorption, distribution, metabo- preeclampsia: a condition during late pregnancy characterized by
lism, and elimination of drugs edema, proteinuria, and hypertension; can lead to eclampsia or
pharmacology: the study of drugs, their processes, origin, nature, seizures if not treated
properties, uses, and effects pressure: a force exerted against the walls of a container; for exam-
phlebostatic axis: the location of the right atrium, found by drawing ple, blood pressure can be defined as the force exerted against the
an imaginary line from the fourth intercostal space at the right walls of a blood vessel
side of the sternum to an intersection with the midaxillary line pressure-limited/volume-variable ventilator: a type of mechanical
phlebotomist: the member of the health-care team who performs ventilation when the pressure delivered by the ventilator is preset
venipuncture by the clinician and the volume is dependent upon the airway
phlebotomy: the opening of a vein to draw blood resistance and lung compliance
phlegm: the common or nonmedical term used to describe thick mu- pressure ventilator: a ventilator designed to deliver a clinician-
cus produced in the airways selected pressure
phonation: the utterance of vocal sounds; speech preterm: being born before completion of the normal gestational
piezoelectric: the generation of a voltage in a solid when a mechani- period; premature
cal stress is applied; the conversion of one form of energy to an- professionalism: the conduct displayed by an individual dictated by
other, such as electrical into mechanical a code of behavior determined a particular profession
Pin Index Safety System (PISS): used to connect regulators to small, proficiency: competency; performance with correctness and facility
high-pressure cylinders prokaryotic: a cell without a true nucleus
pinna: the auricle or external ear proliferation: rapid growth and multiplication
placenta: a highly vascular organ that supplies oxygen and nutrients prone: lying face down
to a developing fetus propellant: an agent incorporated into a mixture in order to cause a
placenta previa: a malposition of the placenta in which it blocks the forceful expulsion
opening to the cervix prophylactic: a preventive agent
plateau: a level or stable event or place prophylaxis: the prevention of the development or spread of disease
platypnea: dyspnea in the upright position protein binding: bonding of a drug with plasma albumin, decreasing
pleural effusion: an abnormal accumulation of fluid in the pleural biological availability
space protocol: a set policy or set of steps to be used
pleural friction rub: a grating noise heard on auscultation associated proximal: the nearest point of reference
with inflammation of the pleural linings pulmonary capillary wedge pressure: intravascular pressure mea-
pleural space: a potential space between the visceral and parietal sured by the distal tip of a flow-directed pulmonary artery cath-
layers of the lining of the lungs eter (Swan Ganz) when the balloon is inflated; this lodges the
pleuritic (pain): pertaining to the pleura, a sharp stabbing localized catheter tip into the vessel and occludes all blood flow past that
pain point, giving a pressure measurement equivalent to the left ven-
pneumatic: pertaining to gas or air tricular preload
pneumatocele: a large, thin-walled, air-filled cyst pulmonary vascular resistance: a force opposing the flow through
pneumoconiosis: a lung disease associated with the inhalation of the pulmonary capillary bed, related to density, velocity, length,
dust, often occupation related and radius of the vessels
pneumotachometer: a device that measures the flow of respiratory gases purulent: consisting of pus
pneumothorax: the accumulation of air in the pleural space pus: a collection of dead cells and debris associated with infection; a
point of care: a term used to describe the ability to perform a service product of liquefaction necrosis
immediately; this is illustrated by the ability to analyze a blood
gas sample where the puncture was performed without having to quadriplegia: paralyzed in all four extremities, usually from the neck
transport the sample to a remote laboratory for analysis down (same as tetraplegia)
polarograph: a device that works by estimating the concentration of
elements in an electrochemical cell that can be reduced or pro- racemic: containing equal parts of both levo and dextro forms of the
duce electrons during an oxidation-reduction reaction tereoisomers
polarographic: utilizing the electrochemical properties of oxygen in radiodense: resistant to penetration of x-rays; radiopaque or “white”
order to determine the concentration of oxygen in a mixture radiolucent: able to be penetrated by x-rays; “black”
polycythemia: increase in the amount of red blood cells or rales: crackles heard on auscultation created by fluid-filled alveoli, or
hemoglobin small airways, or atelectasis
polyhydramnios: an abnormal excess of amniotic fluid reagent: a substance used in a chemical reaction to detect, measure,
polyps: a growth or mass protruding from a mucous membrane or produce other substances
poncho: a blanketlike cloak with a hole for the head receptor: a specialized area in a cell that recognizes and bonds with
pop-off: a term used to describe various release mechanisms used to specific substances producing some effect on the cell
relieve excess pressure in a system recoil: to return to original shape
positive expiratory pressure (PEP): the application of positive expi- reducing valve: a device used to decrease the high pressure in a gas
ratory pressure on the airways; an example of PEP is pursed-lip cylinder to a lower working pressure
breathing redundancy: duplication or repetition; excess above what is required
positive pressure: a force exerted greater than atmospheric pressure refractory: resisting stimulation or treatment
posterior: toward the back regression equation: a formula for the calculation of a variable ap-
postterm: postmature; being born after a prolonged gestational period proaching the mean value in a statistically significant relationship
potency: the power or strength of a medicinal agent to produce among several variables
desired effect regulator: a combination reducing valve and flowmeter; used to de-
potentiation: the enhancement of one agent by another to increase crease the pressure of a gas cylinder and control the output flow
effect (e.g., 1 ⫹ 1 ⫽ 3) relative humidity: percent of the actual atmospheric moisture to the
pounds per square inch (psi): a unit of measure for pressure maximum capacity that could be present at a specific temperature
pounds per square inch above gauge (psig): a unit of measure for reliability: the extent of reproducibility of a test or device with differ-
pressure in which atmospheric pressure is the baseline and only ent investigators, or administration of a test over time
the pressure above atmospheric is measured repolarization: the return of ionic distribution to a resting state
preanalytical: occurring before analysis or laboratory examination reproducibility: repeatability; duplication of a similar structure, situ-
of a specimen ation, or phenomenon
precision: repeatability; the statistical quality control of a measurement reservoir: a storage chamber or receptacle for fluids
2679_Glossary_811-820.indd 817 07/02/13 4:49 PM

818 • GLOSS ARY
resistance: the opposition to force or flow stenosis: abnormal constriction or narrowing
resonance: an echo or sound produced by percussion of an organ or sterilization: the removal or destruction of all living organisms, in-
cavity; related to the frequency of vibration cluding spores
respiration: the exchange of gases across a semipermeable membrane stoma: a hole or opening; similar to a mouth
resuscitation: the process of sustaining the vital functions of a person stridor: a high-pitched crowing sound on inspiration usually due to
in respiratory or cardiac failure while reviving the person an upper airway obstruction
reticulogranular: a description of the chest x-ray finding of cloudi- subcutaneous emphysema: air in the tissue under the skin; creates
ness as found in respiratory distress syndrome crepitus
retractions: a drawing back of soft tissue between the ribs during subcutaneous: beneath the layers of skin
labored breathing subglottic: below the glottis; cricoid area
rhonchi: rumbling sounds on auscultation from fluid in the larger sublimation: the process of vaporizing a solid to a gas without pass-
airways; usually more pronounced on expiration and clearing ing through the liquid phase
with a cough suction control chamber: a component of a chest tube drainage sys-
rigid bronchoscopy: a bronchoscope that is larger and stiffer than a tem related to the amount of negative pressure being applied to
flexible fiber optic bronchoscope the system
superimposed: on top of; occurring at the same time
safety: without danger or harm superior: above or top portion
scale: The size or view of an image or projection supine: lying face upward on back
scoliosis: a lateral curvature of the spine supraglottic: above the glottis or opening to the larynx
sedation: administration of a drug to allay irritability or excitement; surfactant: a surface-active, or detergent-like, agent; a phospholipid
calming effect substance secreted by type II alveolar cells to reduce surface tension
segment: the smaller distal portion of an organ or structure surrogate: a substitute
Sellick maneuver: the application of cricoid pressure during orotra- symbiosis: mutualism; a mutually beneficial relationship
cheal intubation in order to prevent regurgitation symmetrical: correspondence in size, form, and arrangement of parts
semi-Fowler’s position: an elevated position with the head of the on opposite sides
patient at least 30⬚ elevated sympatholytic: an antagonist to the sympathetic system (antiadrenergic)
sensitivity: a capacity to feel, transmit, or react to a stimulus sympathomimetic: mimics the sympathetic system
sensor: a device designed to respond to a physical stimulus and sympathy: the concern of the emotional and physical concerns of
transmit the resulting impulses another; compare to the definition of empathy
sensorium: psychiatric consciousness; intelligent functional ability synchrony: occurs at the same time
sepsis: the presence of disease-producing organisms in the blood syncope: fainting
causing a systemic infection, shock synergism: the joint action of agents or organisms; the combined
septicemia: the presence of bacteria in the blood to a point of disrup- effect is greater than the sum of individual actions; enhances
tion of homeostasis action (1 ⫹ 1 ⫽ 3)
serous: resembling serum; thin, watery, delicate systemic: pertaining to or affecting the body as a whole
sharps container: a punctureproof receptacle used for the disposal of systemic vascular resistance: forces opposing blood flow in the main
sharp objects such as needles circulation
shunt: perfusion without ventilation (true shunt) or in excess of ven- systole: a period of contraction of the heart
tilation (shunt effect); low ventilation/perfusion (V/Q) ratio systolic pressure: the peak force exerted during contraction phase of
sinusitis: an inflammation or infection of the nasal sinuses the ventricles
slope: an angle of incline upward or downward
solubility: the ability to be dissolved tachycardia: an abnormally rapid heart rate, greater than 100 bpm
soluble: able to dissolve in an adult
solute: a substance that dissolves in another substance tachyphylaxis: a sudden marked decrease in effect from repeated
solution: a homogeneous mixture of two or more substances administration; rapid tolerance
solvent: the liquid portion of a solution capable of dissolving an- tachypnea: a rapid rate of breathing
other substance tandem: an arrangement of two or more objects
somnolent: sleepy, drowsy targeting schemes: the ability of a ventilator to adjust ventilation
spacer: an auxiliary device used on a metered-dose inhaler (MDI) to based on target values set by the clinician
reduce the impaction of aerosol particles on the pharynx tenacious: adhesive, thick
specific gravity: the weight of a substance compared with the weight tetany: a sustained muscle contraction or spasm, without twitching
of an equal amount of some other substance (usually water for The Joint Commission: formerly the Joint Commission for
liquids) taken as a standard Accreditation of Healthcare Organizations (JCAHO); a private
specificity: a quality of reacting with only certain substances or hav- organization not associated with the government that establishes
ing only certain actions or effects guidelines for the operation of hospitals and home care agencies;
spectrophotometry: a technique of measurement using the absorp- their policies and programs are associated with quality delivery
tion of visible light by a substance of health care; accreditation by The Joint Commission is essential
sphygmomanometer: an instrument for measuring arterial blood for recognition by insurance companies, especially Medicare
pressure thermophilic: heat loving
spirometer: an instrument for measuring inhaled or exhaled lung thoracic pump: a phenomenon in which the subatmospheric pres-
volumes sure in the chest cavity aids in venous return
splint: support; device to fix movable parts in order to lessen pain or thrombus: a blood clot, often obstructing a vessel
promote healing thrush: a term used to describe candidiasis, a fungal infection caused
spontaneous breathing test (SBT): a trial of breathing without the use by Candida albicans
of a mechanical ventilator used as a predictor of weaning readiness thumb control: an apparatus controlled by the action of the thumb
sputum: the mucus produced in the lung that is coughed up and tidaling: Fluctuations in the water seal chamber in a chest tube
expectorated drainage system seen during tidal breathing
standard deviation (SD): a statistical term measuring the dispersion of time: a parameter of mechanical ventilation related to the passage of
a random variable; the square root of the average squared devia- conventional time measurement
tion from the mean; for data with a normal distribution, 68% of titrate: to analyze by incrementally adding a fluid of a known
data points will fall within 1 SD, and 95% will fall within 2 SD strength until a given endpoint is reached
static: at a constant level; stoppage of flow tocolytic: related to the disruption of premature labor
2679_Glossary_811-820.indd 818 07/02/13 4:49 PM

tolerance: a decreased response or sensitivity to subsequent repeated vascular: pertaining to blood vessels
doses of the same substance or need for increasing doses to main- vasoconstriction: a decrease in the diameter of blood vessels
tain a constant response vasodilation: a relaxation or widening of blood vessels
tomography: an image technique producing single-image planes or vector: an agent such as insect that transmits disease from sick hu-
slices man to another person; directional force
tonicity: the effective osmotic pressure venesection: an alternate term for phlebotomy
topical: applied to a certain area, such as the skin or mucous mem- venipuncture: the procedure used to puncture a vein for the purpose
brane, for localized effect of obtaining blood
torr: a unit of pressure = 1 mm Hg ventilation: bulk movement of gases in and out of the lungs
tortuous: comprised of twists and turns, as in a tortuous aorta ventilator dependence: a term used to describe the inability to be
tourniquet: a device for compression of a blood vessel weaned from mechanical ventilation
toxicology: the study of the harmful effects of drugs in an organism ventricle: a cavity or chamber of a body part or organ; the lower
tracheomalacia: a softening or destruction of tracheal connective heart chambers
tissue resulting from the increased pressure of an improperly in- Venturi: a tube designed with a constricted point to increase the veloc-
flated endotracheal or tracheostomy tube cuff ity of flow in order to entrain air or fluid into the main flow of gas
tracheostomy: a tube inserted into an opening in the windpipe to vernix: a cheesy coating on the skin of the fetus
provide an airway, or the opening itself virology: the study of viruses
tracheotomy: a surgical procedure to create a tracheostomy virulence: the degree of pathogenicity; the ability to invade, prolifer-
tragus: a cartilaginous projection anterior to the meatus of the ear ate, and cause disease
transcutaneous: through the skin virulent: an agent that has an increased degree of pathogenicity
transducer: a device that converts one physical quantity to another viscosity: resistance to flow; physical property dependent on friction;
(e.g., pressure to electrical) thickness
transillumination: a passage of strong light through a body structure volatile: evaporating rapidly
to permit inspection of an observer on the opposite side volume: the space occupied by an object; in mechanical ventilation,
transpulmonary pressure: a difference in pressure between the it refers to the amount of space occupied by an amount of air
alveoli and pleural space volume limited/pressure variable: a term applied to mechanical ven-
transudate: fluid low in protein; passed through membrane by tilation where the volume is predetermined by the clinician and
altered hydrostatic or osmotic pressure the amount of pressure required to deliver the volume is depen-
Trendelenburg position: a position that involves the patient lying dent upon lung compliance and airway resistance
inclined with the head lower than the feet volume ventilator: a mechanical ventilator designed to deliver a des-
turbulent: flow with chaotic, irregular eddies ignated volume of gas
turgor: a condition of fullness; the extent of swelling or congestion volutrauma: a physical injury to lung tissue caused by excessive volumes
tympanitic: drumlike
water-seal chamber: a component of a chest tube drainage system
umbilical artery: a vessel in the cord that connects the fetus to the related to the volume of water required to maintain a closed sys-
placenta; returns blood from the fetal heart to the placenta tem, or seal, between the lung and the drainage system
umbilical vein: a vessel in the cord that connects the fetus to the weaning: the process of gradually withdrawing from life support
placenta; returns blood from the placenta to the fetus wheal: a raised, round, red lesion of the skin, usually edematous and
unifocal: originating from one point itchy; a welt
unilateral: affecting one side only wheezing: making a polyphonic high-pitched noise, a whistling
uvula: a pendant-like, fleshy mass; structure in back of the throat sound, usually due to narrowing of the airways
whispered pectoriloquy: the transmission of a muted or whispered
Vacutainer®: a blood-collecting device used during phlebotomy sound through the lung parenchyma that is indicative of con-
vacuum: the absence of or decrease in pressure, creating suction solidation
validity: extent to which a measuring device measures what it in- wye: a branching or bifurcated connection shaped like the letter “y”
tends or purports to measure; must be precise, accurate, reliable, (e.g., from a ventilator circuit to an artificial airway)
and reproducible
vallecula: a depression or furrow; a groove behind the epiglottis x-axis: The horizontal direction of a graph
valve stem: a projection used to turn a control device or stopcock
vane: a thin, flat or curved object that is rotated about an axis by a y-axis: The vertical direction of a graph
flow of fluid
variability: differences among items; the quality of being changeable
2679_Glossary_811-820.indd 819 07/02/13 4:49 PM

2679_Glossary_811-820.indd 820 07/02/13 4:49 PM
Index
A performance evaluations, 317–318, 381–386

ABC (airway, breathing, circulation), 70–73 resecuring and repositioning endotracheal tube, 373
Abdomen, patient assessment, 74–75 Airways, intubation. See also Endotracheal airways
Abdominal breathing techniques, 278–280 intubation equipment and preparation, 336–341
Abdominal incisions, splinting, 239 orotracheal intubation, 341–346
Acapella device, 276–277 performance evaluations, 349–352
Acetylcysteine, 807 securing tubes, 347–348
Acid–base status, blood gases, 454–455, 458, 805–806 Alarms, home care ventilators, 773
Adaptive targeting, ventilators, 663 Alarms, ventilators, 680–681
Adenovirus, 29 Albuterol, 806
Adrenergic blocking agents, 78 Allen’s test, modified, 412–413
Advair Diskus, 213 Alupent, 806
AeroEclipse BAN nebulizer, 216–217 Alveolar ventilation (VA)
Aeroneb Pro, 216–217 bedside assessment, 113–114
Aerosol generators laboratory report, bedside assessments, 117–120
aerosol delivery devices, 190–192 American Heart Association (AHA)
gas titration, 193 cardiopulmonary resuscitation (CPR), 70–73
laboratory report, 195–198 American Standard Safety System (ASSS), 125–126
large-volume nebulizers (LVN), 188–190 Analyzers, oxygen, 146–147
metered-dose inhalers, 214–215 Anatomy, heart, 530–531
overview, 187 Aneroid manometer, 372
performance evaluations, 199–200 Aneroid sphygmomanometer, 79–80
specialty nebulizers, 216–217 Anesthesia, body temperature, 76
tandem nebulizer setup, 194 Anxiety, heart rate, 78
ultrasonic nebulizer (USN), 192–193 Apgar scores, 736
Aerosol medication therapy. See also Pharmacology APIE (assessment, problem, implementation, evaluation), 54
dry powder inhaler devices, 213, 218–219 Apnea monitoring, 799–800
filtered nebulizers, 222 Arterial blood gases
laboratory report, 223–228 acid–base calculations, 458
medication administration, 218–221 interpreting values, 454–455
metered-dose inhalers, 219 laboratory report, calculations, 459–463
overview, 211 normal values, 454
performance evaluations, 229–236 oxygenation parameters, calculating, 456–458
small-volume nebulizers, 212–213, 220 performance evaluations, interpretation, 465–466
sputum induction, 222 Arterial blood gases, analyzers
tracheostomy, 221 co-oximetry, 440
Aerosols, culturing techniques, 45 laboratory report, 441–447
Air bubble removal device, 411 maintenance, 438–439
Air compressors, 129 overview, 433
Air entrainment mask, 157, 162–163 performance evaluations, 449–452
Airborne precautions, isolation procedures, 24–33 point-of-care testing, 439–440
Airway using bench-top analyzers, 434–439
Mallampati classification, 340–341 Arterial blood gases, sampling
opening, 71–72 arterial line sampling, 416–419
primary survey, 70–73 arterial puncture, 414–416
Airway pressure release ventilation (APRV), 657 capillary sampling, 420–421
Airway, artificial laboratory report, 423–426
adjuncts, identifying, 310–311 modified Allen’s test, 412–413
airway emergencies, 374–375 overview, 409
bedside assessments, 116 performance evaluations, 427–432
care overview, 369 preparing components, 410–412
cuff pressure measurement, 371–372 Arterial blood pressure, 79–80, 561–564
extubation, 373–374 Arterial line sampling, 416–419, 429–430
humidification, 185–186 Arterial puncture, 412, 414–416, 581
laboratory report, 313–315, 377–379 Artificial airway. See Airway, artificial
laboratory report, bedside assessments, 117–120 Assessment. See Bedside assessments; Patient assessment
minimal leak technique (MLT), 370 Assist/Control ventilation mode, 657–658
minimum occluding volume (MOV), 371 Assisted cough, tracheostomy patients, 275–276
nasopharyngeal airway, insertion, 311 Atelectasis
oropharyngeal airway, insertion, 312 body temperature, 76
overview, 309 chest x-rays, 473–474
821
2679_Index_821-842.indd 821 07/02/13 4:49 PM

822 • INDEX
Atmosphere, gas concentration in, 803 Breathing circuit
Atropine, 807 circuit changes, 683–684
Atrovent, 807 pressure ventilators, 640–641
Auscultation, chest ventilator assembly, 648–649
laboratory report, 103–104 Brethine, 806
performance evaluations, 107–108 Briggs adapter, 191, 221
procedure, 101–102 Bronchial hygiene
Auto-PEEP, measuring, 702 breathing exercises, 278–280
Autoclave, 41, 43 chest percussion, 263
Axillary temperature, 76 chest physiotherapy treatment, 264–265
directed cough, 274–276
expiratory vibration, 264
B inspiratory-resistive muscle training, 280–281
Barrel chest, 96 laboratory report, 267–270, 283–284
Barrier precautions, isolation procedures, 24–33 lung lobes and segments, 258–260
Bedside assessments overview, 257
laboratory reports, 117–120 performance evaluations, 271–272, 285–294
maximum expiratory pressure, 114–115 postural drainage, 261–262
negative inspiratory force, 114–115 vibratory PEP therapy, 276–277
overview, 111–112 Bronchial sounds, auscultation, 101–102
patients with artificial airways, 116 Bronchopulmonary dysplasia, 478
peak expiratory flow rate, 115 Bronchoscopy
performance evaluations, 121–122 identification of components, 614–615
slow vital capacity, 115 laboratory report, 619–621
VT, VE, VA, 113–114 overview, 613
Bennett IPPB machine, 241–245 performance evaluations, 623–624
Beractant, 807 preparation and procedure, 615–616
Bilevel ventilation, goal of, 657 recovery and complications, 617
Biohazard symbol, 42 Bronchovesicular sounds, auscultation, 101–102
Biological monitors, infection control, 44–45 Bronkosol, 806
BiPAP setup, 630–632, 637–638 BTPS correction factors, 503–506
Bitolterol, 806 Bubble humidifiers, 161, 174–175
Blenders, 130, 133–144 Bulk storage systems, 130–131
Blood, infection control, 24–33
Blood gas monitoring. See also Arterial blood gases, analyzers
acid–base calculations, 458 C
capnography, 390–392 Calibration
interpreting values, 454–455 blood gas analyzers, 435
laboratory report, 395–401, 459–463 fluid-filled monitoring system, 555–557
normal and critical values, 805–806 oxygen analyzers, 146–147
normal values, 454 spirometric equipment, 494–495
overview, 387 transducer, 557–558
oxygenation, calculating, 456–458 Capillary refill, 78
performance evaluations, 403–408, 465–466 Capillary sampling, blood gases, 420–421, 431–432
pulse oximetry, 388–390 Capnography
transcutaneous monitors, 392–393 laboratory report, 395–401
Blood gas sampling overview, 390–392
arterial line sampling, 416–419 performance evaluations, 405–406
arterial puncture, 414–416 Cardiac anatomy, 530–531
capillary sampling, 420–421 Cardiac index, 561–564
laboratory report, 423–426 Cardiac output
modified Allen’s test, 412–413 hemodynamic calculations, 561–564
overview, 409 thermodilution, 560–561
performance evaluations, 427–432 Cardiopulmonary pharmacology. See Pharmacology
preparing components, 410–412 Cardiopulmonary resuscitation (CPR), 70–73
Blood pressure Caregiver training, 15–16
hemodynamic calculations, 561–564 Carotid pulse, 73, 77–78
patient assessment, 79–80 Cellulitis, 29
performance evaluations, 91–92 Central venous pressure, 561–564
Blood tests, normal and critical values, 802 Charles’ law, 804
Bloodborne pathogens, 21, 25 Charting
Body fluids, isolation procedures, 24–33 laboratory report, 55–59
Body surface area chart, 563 performance evaluations, 61–68
Body temperature, 76, 78 process for, 54
Body weight, metric conversions, 802 Charting by exception (CBE), 51, 54
Bourdon gauge flow control, 126–127 Checklist charting, 51, 54
Bourdon gauge flowmeter, 126–127 Chemetron wall outlet, 132
Bourdon gauge pressure manometer, 126–127 Chemical dot thermometer, 76
Bourdon gauge regulator, 127–128 Chemical sterilization, 41
Boyle’s law, 804 Chest assessment
Brachial artery, 412 auscultation, 101–102
Brachial pulse, 77–78 inspection, 96–97
Bradycardia, 78, 802 laboratory report, 103–104
Brain injury, 76, 78 palpation, 98–99
Breathing percussion, 100
exercises for, 278–280 performance evaluations, advanced skills, 105–110
laboratory report, breathing techniques, 283–284 Chest physiotherapy
patient assessment, 79 chest percussion, 263
primary survey, 70–73 complete treatment, 264–265
rescue breathing, 71–72 expiratory vibration, 264
2679_Index_821-842.indd 822 07/02/13 4:49 PM

INDEX • 823
laboratory report, 267–270 Co-oximetry, 440
lung lobes and segments, 258–260 Cold sterilization, 41, 43
overview, 257 Colonization, infection control, 29
performance evaluations, 271–272 Combined gas law, 804
postural drainage, 261–262 Combitube (ETC), 309, 345
Chest tubes Communication skills, 17–19, 52–53
dry chest drainage systems, 603–604 Complete blood count (CBC), 802
laboratory report, 607–610 Compliance, manual resuscitation, 297–298
maintaining and troubleshooting, 605 Compressions, CPR, 73
performance evaluations, 611–612 Conjunctivitis, 29
wet chest drainage systems, 602–603 Consolidation, x-rays, 473–474
Chest x-rays Contact precautions, isolation procedures, 24–33
atelectasis or consolidation, 473–474 Continuous mechanical ventilation
endotracheal tube position, 474–475 assembly, 648–649
hyperinflation, 472 controls and testing, 649
infant and pediatric, 476–478 laboratory report, 651–653
kyphoscoliosis, 475 overview, 647
laboratory report, 479–487 pressure, flow, volume, and time, 650
organs and landmarks, 470–471 Continuous positive airway pressure (CPAP), 628–630
overview, 467 goal of, 657
performance evaluations, 489–490 infants, 737–738, 743–744
pneumothorax, 472–473 performance evaluations, 637–638
positions, 469–470 ventilator modes, 660–661
Chicken breath, 275 Control mode, ventilator, 657–658
Children. See Infants; Pediatric patients Conversion factors
Circuits helium mixtures, 804
circuit changes, 683–684 pharmacology calculations, 204
mechanical ventilation, 648–649 spirometry result calculations, 503–506
pressure ventilators, 640–641 Conversion factors, gas cylinders, 129
Circulaire nebulizer, 216–217 Cough reflex, 274
Circulation, primary survey, 70–73 Cough, directed, 274–276, 287–288
Clark’s rule, 807 CPAP. See Continuous positive airway pressure (CPAP)
Clinical Performance Evaluation CPR (cardiopulmonary resuscitation), 70–73
aerosol generators, 199–200 Crepitus, 98–99
aerosol medication therapy, 229–236 Cricoid ring, 344
arterial blood gas analyzers, 449–452 Cromolyn Na, 807
arterial blood gas sampling, 427–432 Croup, 477
artificial airway, 317–318 Cuff pressure measurement, airway, 371–372
blood gas monitoring, 403–408 Cultural diversity, communication skills, 17–19
breathing exercises, 285–286 Cultures, techniques for
bronchoscopy, 623–624 aerosol and gas sources, 45
chest assessment, advanced skills, 105–110 swab cultures, 45
chest physiotherapy, 271–272
chest tubes, 611–612
chest x-rays, 489–490 D
directed cough, 288 Dalton’s law, 803
discontinuation of ventilation, 731–732 Decubiti, 29
drug dosage calculation, 209–210 Dehydration, body temperature, 76
electrocardiography (ECG), 549–552 Delivered oxygen (Fio2), analyzing, 146–148
hemodynamic monitoring, 573–576 Demand-flow regulators, 772
home care settings, 785–800 Diameter Index Safety System (DISS), 125–126
humidfiers, 183–186 Diaphragmatic breathing, 278–279
hyperinflation therapy, 253–255 Digital thermometer, 76
infant care, 743–748 Diphtheria, 29
infection control, 37, 39 Directed cough, 274–276, 287–288
intravenous (IV) catheter, 599–600 Discharge planning, 787–788
laboratory and clinical safety, 12, 14 Disinfecting solution, 29
manual ventilation, 307–308 Disinfection
medical records, 61–68 equipment, preparation for, 43
neonatal/pediatric ventilator initiation, 763–766 handling and disposal of materials, 42–43
noninvasive ventilation, 637–638 methods, overview, 41
oxygen analysis, 151–152 monitoring procedures, 44–45
oxygen supply systems, 139–144 performance evaluations, 49–50
oxygen therapy administration, 172 techniques, laboratory report, 47–48
patient assessment, vital signs, 89–94 Disposable equipment
patient-ventilator system care, 719–720 bubble humidifiers, 161
phlebotomy, 587–588 storage and use, 2
pulmonary function testing, 519–528 Documentation
sterilization and disinfection, 49 chart review, patient interview and history, 52–53
suctioning, 331–334 charting findings, 54
tracheostomy, 365–368 laboratory report, medical record, 55–59
ventilator initiation, 695–698 medical records, overview, 51
Clinical safety performance evaluations, 61–68
evaluation forms, 11–16 Dorsalis pedis pulse, 77–78
laboratory report, 7–9 Dosage calculations, 204
patient positioning, 5 Droplet precautions, isolation procedures, 24–33
professionalism, 2–3 Drug use and abuse, vital signs, 76, 78
scene survey, 5 Drugs. See Pharmacology
Clorox, MSDS for, 4 Dry chest drainage systems, 603–604
Clubbing, fingers, 75 Dry powder inhalers, 213, 218–219
2679_Index_821-842.indd 823 07/02/13 4:49 PM

824 • INDEX
Dual targeting, ventilators, 663 manual resuscitation, 297–298
DuBoid body surface area chart, 563 oxygen analyzer calibration, 146–147
Dull, percussion sounds, 100 oxygen therapy administration, flow rates, 157–158
pressure alarms, ventilators, 680–681
Fire safety, 3
E Flat, percussion sounds, 100
Ear temperature, 76 Flow-directed pulmonary artery catheters, 554–555
Ebola virus, 29 Flow-sensing spirometers, 492–493
ECG. See Electrocardiography (ECG) Flow-time curves, 704
Edema, patient assessment, 75 Flow-volume loops, 507–508
Electrical safety, 3 Flowmeter, Thorbe tube, 128
Electrocardiography (ECG) Fluid-filled monitoring systems, 555–557
artifacts, 534–535 FLUTTER valve, 276–277
cardiac anatomy, 530–531 Foot coverings, 30
cleanup procedures, 536 Forced expiratory volume, spirometry, 503–506
interpretation, 536–537 Forced vital capacity, spirometry, 498–506
laboratory report, 539–548 Forceps, Magill, 345–346
leads, preparation and attachment, 532–534 FRED’s SAFE, 498
machine controls, 531 Fremitus, 98–99
overview, 529 Fried’s rule, 807
performance evaluations, 549–552 Functional reserve capacity (FRC), 803
rules of thumb, 807–808 Funnel chest, 96
Electronic digital thermometer, 76
Electronic respirometer, 113–114
Emboli, x-rays, 467 G
Emergency medical services (EMS) system, 71 Gas cylinders
Emphysema bulk storage systems, 130–131
chest palpation, 98–99 conversion factors, 129
chest x-rays, 472 performance evaluations, 139–144
percussion sounds, 100 reducing valves, regulators, flowmeters, 126–129
Endotracheal airways reference data and calculations, 803–804
airway emergencies, 374–375 storage and handling, 124–126
care and maintenance, 370–373 wall outlets and zone valves, 131–132
extubation, 373–374 Gas laws, 804
intubation equipment and preparation, 336–341 Gas pressure alarms, ventilators, 680–681
laboratory report, care and maintenance, 377–379 Gas sources, culturing techniques, 45
laboratory report, intubation, 349–352 Gas sterilization, 43
manual ventilation, 299 Gas titration, 193
orotracheal intubation, 341–346 Gay-Lussac’s law, 804
overview, 309 Gloves
pediatric patients, 805 standard precautions, 25, 26, 30
performance evaluations, care and maintenance, 381–386 sterile gloves, application of, 31–32
performance evaluations, intubation, 349–352 Glutaraldehyde, 41, 43
securing endotracheal tubes, 347–348 Goggles, 30
tube position, x-ray, 474–475 Gowns
Endotracheal suctioning, 324–326, 331–332 application of, 30
Enteric infections, 29 standard precautions, 25, 26
Epiglottitis, 29, 477
Epinephrine, 806
Equipment H
handling and disposal of, 42–43 Haemophilus influenzae, 29
infection control, 21 Hair coverings, 30
preparing for disinfection or sterilization, 43 Hand hygiene
safety, 2 hand washing, 23–24
Escherichia coli, 29 performance evaluations, 37–40
Esophageal-tracheal Combitube (ETC), 309, 345 standard precautions, 25, 26
Esophagus, intubation, 344 Hard palate, 341
Ethylene dioxide, 41, 43 Hazardous materials, handling and disposal of, 2, 4, 42–43
Exhaled volume alarms, 681 Head, patient assessment, 73–74
Exosurf, 807 Health Insurance Portability and Accountability Act (HIPAA), 51
Expiration Heart block, 78
chest motion, 97 HEART nebulizer, 216–217
patient assessment, 79 Heart rate
Expiratory vibration, 264 normal values, 802
Extremities, patient assessment, 74–75 pulse, location and measurement, 77–78
Extubation, 373–374, 383–384 Heart, anatomy of, 530–531
Eye protection, standard precautions, 25 Heat and moisture exchanger (HME), 175, 648–649
Helium mixtures, 804
Hematoma, 581
F Hemodynamic monitoring
Face mask, aerosol delivery devices, 190–192 calculations, 561–564
Face shield, standard precautions, 25, 30 flow-directed pulmonary artery catheters, 554–555
Face tent, aerosol delivery devices, 191 fluid-filled monitoring system assembly, 555–557
Femoral artery, 412 laboratory report, 565–572
Femoral pulse, 77–78 normal and critical values, 806
Fever, heart rate, 78 overview, 553
Fick equation, 458, 806 performance evaluations, 573–576
Finger clubbing, 75 pressure waveforms, 559–560
Fio2 (delivered oxygen) thermodilution cardiac output, 560–561
air entrainment devices, accuracy of, 163 transducer calibration, 557–558
intermittent positive pressure breathing (IPPB), 243 Henderson-Hasselbach equation, 805
2679_Index_821-842.indd 824 07/02/13 4:49 PM

INDEX • 825
HEPA (high-efficiency particulate aerosol) masks, 32–33 Inspirations, patient assessment, 79
Heparin syringe, 410–412 Inspiratory capacity (IC), 803
Hepatitis A, 29 Inspiratory-resistive muscle training, 280–281, 291–292
Herpes simplex virus, 29 Inspiratory:Expiratory (I:E) ratio, 803
Herpes zoster, 29 Intal, 807
High-efficiency particulate aerosol (HEPA) masks, 32–33 Intelligent targeting, ventilators, 663
High-flow nasal cannula, 154–155 Intermittent mandatory ventilation, 659–660
High-flow nonrebreathing mask, 157 Intermittent positive-pressure breathing (IPPB), 237, 241–245, 255
High-frequency ventilators, 751–752 Intracranial pressure, heart rate, 78
High-pressure alarms, ventilators, 681 Intrapulmonic percussive ventilation (IPV), 293–294
HIPAA (Health Insurance Portability and Accountability Act), 51 Intravenous (IV) catheter
History, patient, 52–53 laboratory report, 595–597
HME (heat and moisture exchanger), 175 maintenance and removal, 593
Home care overview, 589, 590
oxygen therapy, 773–775 performance evaluations, 599–600
performance evaluations, 785–800 preparation and insertion procedure, 590–592
Huffing, 275 rate infusion calculation, 592
Humidifiers Intubated patients, manual ventilation, 299
bubble humidfiers, 174–175 Intubation. See Endotracheal airways
heat and moisture exchanger (HME), 175 Inverse I:E ventilation mode, 657, 659
laboratory report, 178–182 Ipratropium bromide, 807
mechanical ventilation, 648–649 ISO-NEB, 216–217
overview, 173 Isoetharine, 806
oxygen therapy, 158, 161 Isolation procedures
procedural and competency evaluations, 183–186 laboratory report, 35–36
wick humidfiers, 176–177 performance evaluations, 37–40
Humidity deficits, medical gas, 804 standard precautions, 24–33
Hypercapnia, heart rate, 78 Isoproterenol, 806
Hyperinflation therapy Isuprel, 806
computerized lung simulator, 245
incentive spirometry, 238–240
intermittent positive-pressure breathing (IPPB), 241–245 J
laboratory report, 247–252 Jackson tube sizes, 342
overview, 237 Jaw-thrust maneuver, 72
procedural and competency evaluations, 253–255
Hyperinflation, x-rays, 472 K
Hyperresonant, percussion sounds, 100 Kyphosis, 96, 475
Hyperthermia, 76
Hyperthyroidism, heart rate, 78
Hypothermia, 76, 78 L
Laboratory Report
aerosol generators, 195–198
I aerosol medication therapy, 223–228
Immunocompromised patients, 24–33 arterial blood gas analyzers, 441–447
Impetigo, 29 arterial blood gas sampling, 423–426
Incentive spirometry. See also Spirometry artificial airways, 313–315, 377–379
overview, 237 bedside assessments, 117–120
pre- and postoperative instructions, 238–240 blood gas calculations, 459–463
procedural and competency evaluations, 253–254 blood gas monitoring, 395–401
Infants bronchoscopy, 619–621
capillary sampling, 420–421 cardiopulmonary pharmacology, 205–208
chest x-rays, 476–478 chest physiotherapy, 267–270
dosage calculations, 807 chest tubes, 607–610
high-frequency ventilators, 751–752 chest x-rays, 479–487
laboratory report, 739–742, 755–761 communication and diversity, 19
nasal CPAP, 737–738 continuous mechanical ventilation, 651–653
neonatal assessments, 734–737 discontinuation of ventilation, 724–729
orotracheal intubation, 341–346 electrocardiography (ECG), 539–548
performance evaluations, 743–748 endotracheal intubation, 349–352
postural drainage, 261 hemodynamic monitoring, 565–572
suction pressures, 804 humidifiers, 178–182
time-cycled/pressure-limited ventilators, 750–751 hyperinflation therapy, 247–252
transcutaneous monitor placement, 393 infection control, 35–36
ventilation scenarios, 752–754 intravenous (IV) catheter, 595–597
Infection control laboratory and clinical safety, 7–9
equipment sterilization and disinfection, 43–44 manual resuscitation and ventilation, 301–305
hand washing, 23–24 medical record, 55–59
handling and disposal of materials, 42–43 noninvasive ventilation, 633–636
laboratory report, 35–36, 47–48 oxygen analysis, 149–150
monitoring procedures, 44–45 oxygen supply systems, 133–138
overview, 21 oxygen therapy administration, 165–170
performance evaluations, 37–40, 49–50 patient assessment, vital signs, 83–87
respirometer, 113 patient-ventilator system care, 711–718
sterilization and disinfection, overview, 41 percussion and auscultation, 103–104
transmission-based isolation procedures, 24–33 phlebotomy, 583–585
Influenza, infection control, 29 pressure ventilators, 643–645
Inhalers, dry powder, 213, 218–219 pulmonary function testing, 511–518
Inhalers, metered-dose, 214–215, 219 respiratory care in alternative settings, 777–783
Inspiration-expiration (I:E) ratio, 79 sterilization and disinfection, 47–48
Inspiration, chest motion, 97 suctioning, 327–329
2679_Index_821-842.indd 825 07/02/13 4:49 PM

826 • INDEX
Laboratory Report (continued) Minimum occluding volume, airway, 371
tracheostomy care, 363–364 Minute ventilation (VE)
ventilator initiation, 685–694 bedside assessment, 113–114
ventilator modes, 665–678 laboratory report, bedside assessments, 117–120
Laboratory safety normal values, 112
evaluation forms, 11–16 Mouth-to-mask ventilation breathing, 72, 298
laboratory report, 7–9 Mouth-to-mouth breathing, 72
professionalism, 2–3 Mouth-to-nose breathing, 72
Laboratory values, normal and critical, 802–803 Mouth-to-stoma breathing, 72
LaPlace’s law, 804 MRSA (methicillin-resistant Staphylococcus aureus), 29
Large-volume nebulizers (LVN), 188–190, 199–200 MSDS (Material Safety Data Sheets), 2, 4
Laryngeal mask airways (LMAs), 309, 345 Mucomyst, 807
Laryngoscope blades, type and size, 342 Mucus clearance, directed cough, 274–276
Lassa virus, 29 Mumps, 29
Levey-Jennings plot, 436–437 Mycoplasma pneumoniae, 29
Linens, standard precautions, 25
Listening skills, 53
Low exhaled volume alarms, 681 N
Low-pressure alarms, ventilators, 681 Nail polish, pulse oximetry, 389
Luer-Lok needle protection, 411 Nasal airways, overview, 309
Lung capacity, 803 Nasal cannula
Lung volumes, normal values, 803 bedside assessments, 112
Lung volumes, spirometry, 497–498 device components, 154–155
Lungs. See also Bronchial hygiene oxygen therapy administration, 157–158
lobes and segments, 258–260 Nasopharyngeal airways, 309, 311
percussion sounds, 100 Nasotracheal intubation, 345–346
simulator, 245 Nasotracheal suctioning, 319, 323, 333–334
National Institute Occupational Safety and Health (NIOSH), 32
Nebulizers
M aerosol delivery devices, 190–192
Macintosh blade, 341–346 filtered nebulizers, 222
Magill forceps, 345–346 intermittent positive-pressure breathing (IPPB), 241–245
Mallampati classification, 340–341 laboratory report, 195–198
Manual resuscitators large-volume nebulizers (LVN), 188–190
assembly and disassembly, 296 overview, 187
during compressions, 300 procedural and competency evaluations, 199–200, 229–236
intubated patients, 299 small-volume nebulizers, 212–213, 220
laboratory report, 301–305 specialty nebulizers, 216–217
mouth-to-mask ventilation, 298 tandem nebulizer setup, 194
overview, 295 ultrasonic nebulizer, 192–193
pressure relief valves, 297 Neck, patient assessment, 73–74
pressure, stroke volume, Fio2 measurement, 297–298 Needles
procedural and competency evaluations, 307–308 blood gas sampling kits, 410–412
in spontaneously breathing patient, 300 handling and disposal of, 42–43
ventilation with mask, 299 intravenous (IV) catheter insertion, 590–592
Manual ventilation, overview, 295 phlebotomy troubleshooting, 580–581
Marburg virus, 29 safety, 2
Masks venipuncture, 579–581
aerosol medication delivery, 220 Negative inspiratory force
HEPA filter masks, 32–33 bedside assessments, 114–115
oxygen therapy devices, 154–157 laboratory report, bedside assessments, 117–120
standard precautions, 25 normal values, 112
wearing of, 30 Negative-pressure ventilator, 627–628
Material Safety Data Sheets (MSDS), 2, 4 Neisseria meningitidis, 29
Maxair, 806 Neonates
Maxair Autohaler, 214–215 capillary sampling, 420–421
Maximum expiratory pressure (MEP) chest x-rays, 476–478
bedside assessments, 114–115 dosage calculations, 807
laboratory report, bedside assessment, 117–120 high-frequency ventilators, 751–752
normal values, 112 laboratory report, 739–742, 755–761
Mean arterial pressure (MAP), 806 nasal CPAP, 737–738
Mean pulmonary artery pressure, 806 orotracheal intubation, 341–346
Mechanical percussor, 263 patient assessment, 734–737
Mechanical ventilation. See Ventilation, mechanical performance evaluations, 743–748
Medical record time-cycled/pressure-limited ventilators, 750–751
chart review, patient interview and history, 52–53 transcutaneous monitor placement, 393
charting findings, 54 ventilation scenarios, 752–754
laboratory report, 55–59 Noninvasive ventilation
overview, 51 BiPAP setup, 630–632
performance evaluations, 61–68 continuous positive airway pressure (CPAP), 628–630, 657,
Medication. See Pharmacology 660–661
Meningitis, 29 infants, 737–738, 743–744
Metabolic effects, pulse oximetry, 390 laboratory report, 633–636
Metaproterenol, 806 negative-pressure ventilator, 627–628
Metered-dose inhalers, 214–215, 219 overview, 626
Methicillin-resistant Staphylococcus aureus (MRSA), 29 performance evaluations, 637–638
Metric conversions, 802 Nonrebreathing mask, 156, 160, 161
Micronephrin, 806 Nonrebreathing valves, 296
Miller blade, 342, 345 Nonverbal communication, 53
Minimal leak technique (MLT), airway cuff, 370 Nosocomial infections, isolation procedures, 24–33
2679_Index_821-842.indd 826 07/02/13 4:49 PM

INDEX • 827
O Patient interview, 51, 52–53, 65–66
Occupational Safety and Health Administration (OSHA) Patient positioning, 5, 13–14, 467, 469–470
HEPA masks, 32 Patient training, 15–16
workplace safety standards, 3 Patient transport, 26–28
Ohm’s Law, 804 Peak expiratory flow, bedside assessments, 115, 117–120
Ohmeda wall outlet, 132 Peak flow, normal values, 112
Oral temperature, 76 Peak flowmeter, 115
Oropharyngeal airways Pectus carinatum, 96
insertion of, 312, 341–346 Pectus excavatum, 96
overview, 309 Pediatric patients. See also Infants
Oropharyngeal suctioning, 322 chest x-rays, 476–478
Oxygen analysis dosage calculations, 807
analyzer calibration, 146–147 ET tube size calculation, 805
analyzer components, 146 normal vital signs, 802
blood gas calculations, 456–458 orotracheal intubation, 341–346
competency and clinical performance evaluation, 151–152 suction pressures, 804
laboratory report, 149–150 ventilation scenarios, 754
overview, 145 Pediculosis, 29
procedure for, 147–148 PEEP (positive end-expiratory pressure) ventilator mode, 657,
Oxygen blender, 130, 133–144 660–661, 702
Oxygen concentrators, 771 Pentam, 807
Oxygen hood, 745–746 Pentamidine, 807
Oxygen supply systems PEP (positive expiratory pressure) therapy, 276–277, 289–290
air compressors, 129 PEP mask therapy, 276–277
blenders, 130 Percent shunt, 561–564
bulk storage systems, 130–131 Percussion
cylinder conversion factors, 129 chest percussion technique, 100, 263
gas cylinder storage and handling, 124–126 laboratory report, 103–104
laboratory report, 133–138 procedural and competency evaluations, 293–294
overview, 123 Percussion cups, 263
performance evaluations, 139–144 Performance evaluation, common elements, 809. See also Clinical
portable liquid systems, 770 Performance Evaluation; Procedural Competency
reducing valves, regulators, flowmeters, 126–129 Evaluation
zone valves and wall outlets, 131–132 Perfusion, pulse oximetry, 390
Oxygen tent, 747–748 Personal protective equipment (PPE)
Oxygen therapy administration application of, 30–33
air entrainment (Venturi) masks, 162–163 disposal of, 42–43
device identification, 154–157 safety overview, 2
discharge planning, 774 transmission-based isolation procedures, 24–33
disinfection, 773 Pertussis, 29
home care, 773 pH blood
laboratory report, 165–170, 777–783 acid–base calculations, 458
long-term therapy, 768–769 normal values, 454–455, 805
nasal cannula, 157–158 Pharmacology
overview, 153 aerosol medication therapy, 211, 218–221
oxygen concentrators, 771 dilution and dosage formulas, 806–807
oxygen-conserving devices, 771–772 drug dosage calculations, 204
performance evaluations, 171–172, 785–800 dry powder inhalers, 213
portable liquid oxygen systems, 770 laboratory report, 205–208, 223–228
simple mask, 160 metered-dose inhalers, 214–215
transtracheal catheters, 159 overview, 201
troubleshooting, 163–164 procedural and competency evaluations, 209–210
Oxyhemoglobin dissociation curve, 456–457 small-volume nebulizers, 212–213
terminology, 203–204
Pharyngeal airway insertion, 317–318
P Phlebotomy
Palate, intubation, 341 laboratory report, 583–585
Palpation, chest, 98–99 overview, 577
Paradoxical expiration, 97 performance evaluations, 587–588
Paradoxical inspiration, 97 preparation and procedure, 579–580
Parainfluenza virus, 29 troubleshooting, 580–581
PARI nebulizer, 216–217 veins, location of, 578
Partial rebreathing mask, 156, 160, 161 Pigeon breast, 96
Pasteurization, 41, 43 Pin Index Safety System (PISS), 125–126
Patient assessment. See also Bedside assessments PIP (problem, implementation, plan), 54
chest auscultation, 101–102 Pirbuterol, 806
chest inspection, 96–97 Pitting edema, 75
chest palpation, 98–99 Pleur-evac, 602–604
chest percussion, 100 Pleural effusion, percussion sounds, 100
laboratory report, advanced skills, 103–104 Pneumonia, 29
laboratory report, vital signs, 83–87 Pneumonic plague, 29
neonates, 734–737 Pneumotachometers, 492–493
normal and critical values, 802–803, 807 Pneumothorax
overview, 69 chest x-rays, 467, 472–473
performance evaluations, advanced skills, 105–110 percussion sounds, 100
performance evaluations, vital signs, 89–94 Point-of-care blood gas analysis, 439–440
primary survey, 70–73 Poiseuille’s law, 804
secondary survey, 73–75 Popliteal pulse, 77–78
vital signs, 76–80 Portable liquid oxygen systems, 770
Patient history, 52–53 Posey Cufflator, 372
2679_Index_821-842.indd 827 07/02/13 4:49 PM

828 • INDEX
Positioning, patient, 5, 13–14, 467, 469–470 Pulmonary mechanics, assessment of
Positive end-expiratory pressure (PEEP) therapy, 657, 660–661, 702 laboratory report, 117–120
Positive expiratory pressure (PEP) therapy, 276–277, 289–290 overview, 111
Posterior tibial pulse, 77–78 performance evaluations, 121–122
Postural drainage, 261–262 Pulmonary vascular resistance, 561–564, 806
Preoperative instructions, spirometry, 238–240 Pulmonary wedge pressure, 561–564
Pressure alarms, ventilators, 680–681 Pulse
Pressure control ventilation mode, 657, 659 carotid pulse, 73
Pressure relief valve, cylinders, 126–127 location and measurement, 77–78
Pressure relief valve, resuscitators, 297 performance evaluations, 89–90
Pressure support, ventilation mode, 657, 661–662 Pulse oximetry
Pressure ventilators laboratory report, 395–401
adult breathing circuit, 640–641 measuring saturation and pulse, 388–390
initiation and monitoring, 641 patient assessment, 81
laboratory report, 643–645 performance evaluations, 93–94, 403–404
overview, 639 Puritan Bennett wall outlet, 132
pressure, flow, volume, and time, 641 Pursed-lip breathing, 278–280
Pressure waveforms, hemodynamic monitoring, 559–560
Pressure-time curves, 703–704
Pressure-volume loop, 705–706 Q
Primary survey, 70–73 Quality control, blood gas analyzers, 436, 438–439
Privacy, HIPAA, 51
Problem, implementation, plan (PIP), 54 R
Procedural Competency Evaluation Racemic epinephrine, 806
aerosol generators, 199–200 Radial artery, 412
aerosol medication therapy, 229–236 Radial pulse, 77–78
arterial blood gas analyzers, 449–452 Radiodense, 467
arterial blood gas sampling, 427–432 Radiology. See X-rays, chest
artificial airway, 317–318 Radiolucent, 467
blood gas monitoring, 403–408 Radiopaque, 467
breathing exercises, 285–286 Reducing valves, 126–127
bronchoscopy, 623–624 Regulators, gas cylinders, 126–128
chest assessment, advanced skills, 105–110 Rescue breathing, 71–73
chest physiotherapy, 271–272 Resistance, manual resuscitation, 297–298
chest tubes, 611–612 Resonant, percussion sounds, 100
chest x-rays, 489–490 Respirations, patient assessment, 79, 89–90
directed cough, 287 Respiratory quotient (RQ), 803
discontinuation of ventilation, 731–732 Respiratory syncytial virus, 29
drug dosage calculation, 209–210 Respirgard, 216–217
electrocardiography (ECG), 549–552 Respirometer, 113–114
hemodynamic monitoring, 573–576 Resuscitators, manual
home care settings, 785–800 assembly and disassembly, 296
humidifiers, 183–186 during compression, 300
hyperinflation therapy, 253–255 intubated patients, 299
infant care, 743–748 laboratory report, 301–305
infection control, 37, 39 mouth-to-mask ventilation, 298
intravenous (IV) catheter, 599–600 overview, 295
laboratory and clinical safety, 11, 13, 15 pressure relief valves, 297
manual ventilation, 307–308 pressure, stroke volume, Fio2 measurement, 297–298
medical records, 61–68 procedural and competency evaluations, 307–308
neonatal/pediatric ventilator initiation, 763–766 in spontaneously breathing patient, 300
noninvasive ventilation, 637–638 ventilation with mask, 299
oxygen analysis, 151–152 Rib cage
oxygen supply systems, 139–144 barrel chest, 96
oxygen therapy administration, 171 pectus carinatum, 96
patient assessment, vital signs, 89–94 pectus excavatum, 96
patient-ventilator system care, 719–720 Ribavirin, 807
phlebotomy, 587–588 Right ventricular pressure, 561–564
pulmonary function testing, 519–528 Rotating vane spirometer, 113–114
sterilization and disinfection, 49 Rotovirus, 29
suctioning, 331–334 Routes of transmission, infection, 25
tracheostomy, 365–368 Rubella, 29
ventilator initiation, 695–698
Professionalism, 2–3
Proventil, 806 S
Pulmonary artery catheters, flow-directed, 554–555 Safety. See also Infection control
Pulmonary artery pressure, 561–564 evaluation of, 11–16
Pulmonary emboli, x-rays, 467 gas cylinders, storage and handling, 124–126
Pulmonary function testing (PFT) hazardous material handling and disposal, 2, 4, 42–43
calculation of results, 503–506 home evaluation, 774–775
equipment calibration, 494–495 scene survey, 5
equipment identification, 492–493 suctioning, 319
flow-volume loops, 507–508 Salmeterol xinafoate, 806
laboratory report, 511–518 Scabies, 29
maximum voluntary ventilation, 506–507 Scarlet fever, 29
overview, 491 Scene survey, 5
performance evaluations, 519–528 Schrader wall outlet, 132
postbronchodilator study, 506 Scoliosis, 96, 475
respiratory history, 496 Secondary survey, patient assessment, 73–75
spirometry screening, 496–502 Semi-Fowler’s position, 5
2679_Index_821-842.indd 828 07/02/13 4:49 PM

INDEX • 829
Sepsis, 29 T
Serevent, 806 T-piece resuscitator, 735
Servo targeting, ventilators, 663 T-piece, aerosol medication delivery, 221
Sharps, handling and disposal of, 2, 42–43 Tachycardia, 78, 802
Shigella, 29 Tactile fremitus, 98–99
Shock, 76, 78 Temperature, body, 76, 78
Shunt calculation, 564, 805–806 Terbutaline, 806
SIMV ventilation mode, 657 TherePEP device, 276–277
Slow vital capacity Thermodilution cardiac output, 560–561
bedside assessment, 115 Thermometers, 76
calculating, 503–506 Thorpe tube flowmeter, 128
laboratory report, 117–120 Threshold-resistive inspiratory muscle-training device,
spirometry, 498–502 280–281
Small-volume nebulizers, 212–213, 220 Thumb sign, 477
Sniffing position, 342 Tidal volume (VT)
SOAP method, 51, 54 bedside assessment, 113–114
Sodium hypochlorite, 29 laboratory report, bedside assessments, 117–120
Soft palate, 341 normal values, 112
Sphygmomanometer, 79–80 Time-cycled/pressure-limited ventilators, 750–751
Spine, 96, 98 Titration, aerosol delivery, 193
Spiriva, 213 Tornalate, 806
Spirometry Total lung capacity (TLC), 803
accuracy of, 808 Tracheal sounds, auscultation, 101–102
calculation of results, 503–506 Tracheobronchial tree, 260
equipment calibration, 494–495 Tracheostomy
equipment identification, 492–493 aerosol delivery devices, 190–192
flow-volume loops, 507–508 aerosol medication delivery, 221
laboratory report, pulmonary function testing, assisted cough, 275–276
511–518 care and cleaning, 360–362
normal and critical values, 112, 803 laboratory report, 363–364
overview, 237 overview, 309, 355
performance evaluations, 519–528 performance evaluations, 365–368
pre- and postoperative instructions, 238–240 stoma swab cultures, 45
pulmonary function testing, overview, 491 tubes and devices, 356–359
respiratory history, 496 Transcutaneous blood gas monitors, 392–393, 407–408
spirometry screening, 496–502 Transducer calibration, 557–558
Splinting, abdominal incisions, 239 Transmission routes, infection, 25
Sputum induction, 222, 235–236 Transmission-based isolation
Sputum, sample collection, 326 laboratory report, 35–36
Standard precautions performance evaluations, 37–40
isolation procedures, 24–33 procedures, 24–33
laboratory report, 35–36 Transport, patients, 26–28
performance evaluations, 37–40 Transtracheal catheters, 159
Staphylococcus aureus, MRSA, 29 Tripod position, 97
Steam autoclave, 41 Trumpets, overview, 309
Steeple sign, 477 Tympanitic, percussion sounds, 100
Sterile gloves, application of, 31–32
Sterilization
equipment, preparation for, 43 U
handling and disposal of materials, 42–43 Ultrasonic nebulizer (USN), 192–193
methods, overview, 41 Unconscious patients, primary survey, 70–73
monitoring procedures, 44–45
performance evaluations, 49–50
respirometer, 113 V
techniques, laboratory report, 47–48 Vagal stimulation, heart rate, 78
Stethoscope, 101–102 Vane-type respirometer, 115
Stoma Vaponephrin, 806
mouth-to-stoma breathing, 72 Vascular resistance, 561–564
swab cultures, 45 Veins, phlebotomy, 578
Streptococcal pharyngitis, 29 Venipuncture, 580–581
Stress, heart rate, 78 Venous blood gas values, 454, 456–458
Stroke index, 806 Venous pressure, 561–564
Stroke volume, manual resuscitation, 297–298 Ventilation, manual
Suctioning during compressions, 300
endotracheal suctioning, 324–326 intubated patients, 299
equipment for, 320–321 laboratory report, 301–305
laboratory report, 327–329 with mask, 299
nasotracheal suctioning, 323 mouth-to-mask ventilation, 298
oropharyngeal suctioning, 322 overview, 295
overview, 319 performance evaluations, 307–308
performance evaluations, 331–334 pressure relief valves, 297
sputum sample collection, 326 pressure, stroke volume, Fio2 measurement,
suction kits, 322 297–298
Supine position, 5 rescue breathing, 71–73
Surgical scrub, 24 resuscitators, assembly and disassembly, 296
Survanta, 807 in spontaneously breathing patient, 300
Sustained maximal inspiration (SMI), 237, 238–240 Ventilation, mechanical
Swab culturing, 45 assembly, 648–649
Synchronized intermittent mandatory ventilation, 659–660 controls and testing, 649
Systemic vascular resistance, 561–564 discontinuation, 721–723
2679_Index_821-842.indd 829 07/02/13 4:49 PM

830 • INDEX
Ventilation, mechanical (continued) Virazole, 807
initiation Visitors, standard precautions, 26
alarm parameters, 680–681 Vital capacity (VC)
circuit changes, 683–684 defined, 803
infants and pediatric, scenarios, 752–754 normal values, 112
infants, high-frequency ventilators, 751–752 spirometry measures, 498–502
infants, time-cycled/pressure-limited ventilators, 750–751 Vital signs
laboratory report, 685–694 laboratory report, 83–87
laboratory report, neonatal/pediatric, 755–761 normal and critical values, 802–803
overview, 679 patient assessment, 76–80
performance evaluations, 695–698 performance evaluations, 89–94
performance evaluations, neonatal/pediatric, 763–766 pulse oximetry, 81
scenarios for initiation, 682–683, 752–754 Volume-time curves, 705
laboratory report, 651–653, 724–729
overview, 647
performance evaluation, 731–732 W
pressure, flow, volume, and time, 650 Wall outlets, oxygen supply, 131–132
Ventilation, noninvasive Waste, handling and disposal of, 42–43
BiPAP setup, 630–632 Waveforms, ventilators, 703–708
CPAP (continuous positive airway pressure), 628–630 Weaning, mechanical ventilation
laboratory report, 633–636 laboratory report, 724–729
negative-pressure ventilator, 627–628 overview, 721–723
overview, 626 performance evaluations, 731–732
performance evaluations, 637–638 Wet chest drainage systems, 602–603
Ventilators Wick humidifiers, 176–177
bedside assessments, 112 Wright respirometer, 115
data generation, 702
laboratory report, 711–718 X
overview, 699 X-rays, chest
performance evaluations, 719–720 atelectasis or consolidation, 473–474
pressure ventilators, 639–646 endotracheal tube position, 474–475
setting modification and documentation, 708–709 hyperinflation, 472
ventilator modes infant and pediatric, 476–478
advanced modes, targeting schemes, 662–663 kyphoscoliosis, 475
control and assist/control, 657–658 laboratory report, 479–487
CPAP (continuous positive airway pressure), 660–661 organs and landmarks, 470–471
goals of, 656–657 overview, 467
laboratory report, 665–678 performance evaluations, 489–490
overview, 655 pneumothorax, 472–473
pressure control inverse I:E ratio, 659 positions, 469–470
pressure support mode, 661–662
synchronized intermittent mandatory ventilation, 659–660
ventilator monitoring, basic, 700–701 Y
waveform id and interpretation, 703–708 Young’s rule, 807
Ventolin, 806
Ventricular pressure, 561–564
Venturi mask, 157, 162–163 Z
Vibratory positive expiratory pressure (PEP) therapy, 276–277, Zone valves, 131–132
289–290
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Thomas J. Butler PH.D RRT RPFT - Laboratory Exercises For Competency in Respiratory Care-F.a. Davis Company (201

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Laboratory Exercises

2679_FM_i-xxii.indd i 07/02/13 4:49 PM

Thomas J. Butler, PhD, RRT-NPS, RPFT

2679_FM_i-xxii.indd iii 07/02/13 4:49 PM

Copyright © 2013 by F. A. Davis Company

Printed in the United States of America

Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1

Senior Acquisitions Editor: T. Quincy McDonald

Library of Congress Cataloging-in-Publication Data

2679_FM_i-xxii.indd iv 07/02/13 4:49 PM

2679_FM_i-xxii.indd v 07/02/13 4:49 PM

Contributing Authors xiv CHAPTER 4 Sterilization and

CHAPTER 3 Infection Control 21 CHAPTER 6 Patient Assessment: Basic

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CHAPTER 7 Patient Assessment: CHAPTER 11 Oxygen Therapy

CHAPTER 8 Bedside Assessment of CHAPTER 12 Humidity Devices 173

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2679_FM_i-xxii.indd ix 07/02/13 4:49 PM

CHAPTER 21 Suctioning 319 CHAPTER 25 Noninvasive Blood Gas

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CHAPTER 29 Basic Chest X-ray Procedural Competency Evaluations 549

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CHAPTER 35 Chest Tube Drainage CHAPTER 39 Continuous Mechanical

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CHAPTER 43 Discontinuation CHAPTER 46 Respiratory Care in

2679_FM_i-xxii.indd xiii 07/02/13 4:49 PM

Lisa Shultis, BS, RRT

Dianne A. Adams, MA, RRT, NPS

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2679_FM_i-xxii.indd xv 07/02/13 4:49 PM

2679_FM_i-xxii.indd xvi 07/02/13 4:49 PM

2679_FM_i-xxii.indd xvii 07/02/13 4:49 PM

PROCEDURAL C OMP ETEN CY EVAL UAT I O N S

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P R OCEDUR AL C OMP ETENC Y E VA LU AT I O N S

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2679_FM_i-xxii.indd xxi 07/02/13 4:49 PM

2679_FM_i-xxii.indd xxii 07/02/13 4:49 PM

OBJECTIVES 1. Relate the safety information contained on an MSDS sheet.

2679_Ch01_001-016.indd 1 07/02/13 4:42 PM

EXERCISE 1.1 PROFESSIONALISM

The instructor will review 1. Laboratory schedule, availability, hours, open-lab

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EXERCISE 1.2 AARC GUIDE TO PROFESSIONALISM MODULE

1. Go to the AARC website and review the presentation on professionalism at www.aarc.org/

EXERCISE 1.3 MEDICAL DIRECTOR OR PHYSICIAN INTERACTION

EXERCISE 1.4 SAFETY CONSIDERATIONS

EXER C ISE 1.4.2 F IRE S AF E T Y

EXER C ISE 1.4.3 OS HA S TA N D A R D S

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EXERCISE 1 .4.4 HAZARDOUS MATERI A LS A N D MS D S S H E E T S

Clorox Professional Products Company

Description: CLEAR, LIGHT YELLOW LIQUID WITH CHLORINE ODOR

Other Designations Distributor Emergency Telephone Nos.

II Health Hazard Data III Hazardous Ingredients

IV Special Protection and Precautions V Transportation and Regulatory Data

Fire extinguisher: Location _ Type ___

OSHA regulation no.: _ Date of policy manual: _____________

9. _ 10. _