Ebook Clinical application of mechanical ventilation (4th edition): Part 1

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David W. Chang

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David W. Chang, Ed.D., RRT–NPS
Professor
Department of Cardiorespiratory Care
University of South Alabama
Mobile, Alabama

Australia • Brazil • Japan • Korea • Mexico • Singapore • Spain • United Kingdom • United States

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Clinical Application of Mechanical
Ventilation, Fourth Edition
David W. Chang
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Printed in the United States of America
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Dedicated with love
to my wife, Bonnie and our children,
Michelle, Jennifer, and Michael
for their support in my professional endeavors
and personal leisure activities

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Contents
Preface
Acknowledgments



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Chapter 1: Principles of Mechanical Ventilation
Introduction
Airway Resistance
Factors Affecting Airway Resistance
Airway Resistance and the Work of Breathing (∆P)
Effects on Ventilation and Oxygenation
Airflow Resistance
Lung Compliance
Compliance Measurement
Static and Dynamic Compliance
Compliance and the Work of Breathing
Effects on Ventilation and Oxygenation
Deadspace Ventilation
Anatomic Deadspace
Alveolar Deadspace
Physiologic Deadspace
Ventilatory Failure
Hypoventilation
Ventilation/Perfusion (V/Q) Mismatch

Intrapulmonary Shunting
Diffusion Defect
Oxygenation Failure
Hypoxemia and Hypoxia
Clinical Conditions Leading to Mechancial Ventilation
Depressed Respiratory Drive
Excessive Ventilatory Workload
Failure of Ventilatory Pump

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VIII

Contents

Summary
Self-Assessment Questions
Answers to Self-Assessment Questions
References
Additional Resources


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Chapter 2: Effects of Positive Pressure Ventilation
Introduction

Pulmonary Considerations
Spontaneous Breathing
Positive Pressure Ventilation
Airway Pressures
Compliance
Cardiovascular Considerations
Mean Airway Pressure and Cardiac Output
Decrease in Cardiac Output and O2 Delivery
Blood Pressure Changes
Pulmonary Blood Flow and Thoracic Pump Mechanism
Hemodynamic Considerations
Positive Pressure Ventilation
Positive End-Expiratory Pressure
Renal Considerations
Renal Perfusion
Indicators of Renal Failure
Effects of Renal Failure on Drug Clearance
Hepatic Considerations
PEEP and Hepatic Perfusion
Indicators of Liver Dysfunction
Effects of Decreased Hepatic Perfusion on Drug Clearance
Abdominal Considerations
Effects of PEEP and Increased Intra-Abdominal Pressure
Gastrointestinal Considerations
Nutritional Considerations
Muscle Fatigue
Diaphragmatic Dysfunction
Nutritional Support
Nutrition and the Work of Breathing
Neurologic Considerations

Hyperventilation
Ventilatory and Oxygenation Failure
Indicators of Neurologic Impairment
Summary
Self-Assessment Questions
Answers to Self-Assessment Questions
References

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Contents



IX

Chapter 3: Classification of Mechanical Ventilators
Introduction
Ventilator Classification

Ventilatory Work
Input Power
Drive Mechanism
Piston Drive Mechanism
Bellows Drive Mechanism
Microprocessor-Controlled Pneumatic Drive Mechanism
Control Circuit
Mechanical
Pneumatic
Fluidics
Electronic
Control Variables
Pressure Controller
Volume Controller
Flow Controller
Time Controller
Phase Variables
Trigger Variable
Limit Variable
Cycle Variable
Baseline Variable
Conditional Variable
Terminology of Ventilation Modes
Volume-Controlled Ventilation
Pressure-Controlled Ventilation
Intermittent Mandatory Ventilation (IMV)
Pressure Support
Dual Control within a Breath
Dual Control Breath-to-Breath
Pressure-Limited Time-Cycled Breaths

Pressure-Limited Flow-Cycled Breaths
Automode
Proportional Assist Ventilation
Automatic Tube Compensation
Airway Pressure Release Ventilation
Output Waveforms
Pressure Waveforms
Volume Waveforms
Flow Waveforms
Alarm Systems
Input Power Alarms

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X

Contents

Control Circuit Alarms
Output Alarms
Summary
Self-Assessment Questions
Answers to Self-Assessment Questions
References
Additional Resources


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Chapter 4: Operating Modes of Mechanical Ventilation
Introduction
Negative and Positive Pressure Ventilation
Negative Pressure Ventilation
Positive Pressure Ventilation
Operating Modes of Mechanical Ventilation
Closed-Loop System
Spontaneous
Apnea Ventilation

Positive End-Expiratory Pressure (Peep)
Indications for PEEP
Physiology of PEEP
Complications of PEEP
Continuous Positive Airway Pressure (Cpap)
Bilevel Positive Airway Pressure (Bipap)
Indications for BiPAP
Initial Settings
Adjustments of IPAP and EPAP
Controlled Mandatory Ventilation (Cmv)
Indications for Control Mode
Complications of Control Mode
Assist/Control (Ac)
Assist Control Triggering Mechanism
Assist Control Cycling Mechanism
Indications for AC Mode
Advantages of AC Mode
Complications of AC Mode
Intermittent Mandatory Ventilation (Imv)
Synchronized Intermittent Mandatory Ventilation (Simv)
SIMV Mandatory Breath-Triggering Mechanism
SIMV Spontaneous Breath-Triggering Mechanism
Indications for SIMV Mode
Advantages of SIMV Mode
Complications of SIMV Mode
Mandatory Minute Ventilation (Mmv)
Pressure Support Ventilation (Psv)
Indications for PSV Mode
Adaptive Support Ventilation (Asv)

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Contents

Proportional Assist Ventilation (Pav)
Volume-Assured Pressure Support (Vaps)
Pressure-Regulated Volume Control (Prvc)
Automode
Adaptive Pressure Control (Apc)
Volume Ventilation Plus (VV1)
Volume Control Plus (VC1)
Volume Support (VS)
Pressure-Controlled Ventilation (PCV)
Airway Pressure Release Ventilation (APRV)
Indications for APRV
Biphasic Positive Airway Pressure (Biphasic PAP)
Inverse Ratio Ventilation (IRV)
Physiology of IRV
Adverse Effects of IRV
Pressure Control-IRV (PC-IRV)

Automatic Tube Compensation (ATC)
Neurally Adjusted Ventilatory Assist (NAVA)
High-Frequency Oscillatory Ventilation (HFOV)
Summary
Self-Assessment Questions
Answers to Self-Assessment Questions
References
Additional Resources


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Chapter 5: Special Airways For Ventilation
Introduction
Oropharyngeal Airway
Types of Oropharyngeal Airways
Selection of Oropharyngeal Airway
Insertion of Oropharyngeal Airway
Nasopharyngeal Airway
Selection of Nasopharyngeal Airway
Insertion of Nasopharyngeal Airway
Complications of Nasopharyngeal Airway
Esophageal Obturator Airway (EOA)
Insertion of EOA
Esophageal Gastric Tube Airway (EGTA)
Laryngeal Mask Airway (LMA)
Use of L MA
Contraindications for L MA
Selection of L MA
Insertion of L MA
Removal of LMA
Limitations of LMA

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XII

Contents

Esophageal-Tracheal Combitube (ETC)
Insertion and Use of ETC
Complications of ETC
Double-Lumen Endobronchial Tube (DLT)

Indications
Selection of DLT
Insertion of DLT
Complications of DLT
Summary
Self-Assessment Questions
Answers to Self-Assessment Questions
References
Additional Resources


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Chapter 6: Airway Management in Mechanical Ventilation
Introduction
Intubation
Indications
Common Artificial Airways in Mechanical Ventilation

Endotracheal Tube
Tracheostomy Tube
Specialty Tracheostomy Devices
Intubation Procedure
Preintubation Assessment and Signs of Difficult Airway
Supplies
Special Visualization Devices
Selection of Endotracheal Tube
Ventilation and Oxygenation
Oral Intubation
Nasal Intubation
Common Errors
Signs of Endotracheal Intubation
Signs of Esophageal Intubation
Rapid Sequence Intubation
Indications and Contraindications
Practice Guidelines
Management of Endotracheal and Tracheostomy Tubes
Securing Endotracheal and Tracheostomy Tubes
Cuff Pressure
Minimal Occlusion Volume and Minimal Leak Technique
Endotracheal Suctioning
Endotracheal Tube Changer
Speaking Valves
Contraindications
Safety Requirements

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Contents

Positive Pressure Ventilation
Extubation
Predictors of Successful Extubation
Procedure
Unplanned Extubation
Complications of EndotracheaL Airway
During Intubation
While Intubated
Immediately after Extubation
Following Extubation
Summary
Self-Assessment Questions
Answers to Self-Assessment Questions
References
Additional Resources


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Chapter 7: Noninvasive Positive Pressure Ventilation
Introduction
Terminology
Physiologic Effects of NPPV
Use of Continuous Positive Airway Pressure (cpAP)
Obstructive Sleep Apnea
Use of Bilevel Positive Airway Pressure (Bilevel pap)
Common Interfaces for CPAP and Bilevel PAP
Nasal Mask
Oronasal Mask
Nasal Pillows
Full-Face Mask
Potential Problems with Interfaces
Titration of Continuous Positive Airway Pressure
Autotitration
Ramp
C-Flex™
Titration of Bilevel Positive Airway Pressures
Bi-Flex™
Summary
Self-Assessment Questions
Answers to Self-Assessment Questions
References

Additional Resources



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Chapter 8: Initiation of Mechanical Ventilation
Introduction
Goals of Mechanical Ventilation

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XIV

Contents

Indications
Acute Ventilatory Failure
Impending Ventilatory Failure
Severe Hypoxemia
Prophylactic Ventilatory Support
Contraindications
Initial Ventilator Settings
Mode
Dual Control Mode
Frequency
Tidal Volume
Pressure Support
FIO2
PEEP
I:E Ratio

Flow Pattern
Ventilator Alarm Settings
Low Exhaled Volume Alarm
Low Inspiratory Pressure Alarm
High Inspiratory Pressure Alarm
Apnea Alarm
High Frequency Alarm
High and Low FIO2 Alarms
Hazards And Complications
Types of Hazards and Complications
Malfunction and Misuse of Alarms
Barotrauma
Decrease in Cardiac Output and Blood Pressure
Summary
Self-Assessment Questions
Answers to Self-Assessment Questions
References
Additional Resources


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Chapter 9: Monitoring in Mechanical Ventilation
Introduction
Vital Signs
Heart Rate
Blood Pressure
Respiratory Frequency

Temperature
Chest Inspection
Chest Movement
Auscultation
Imaging

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Contents

Fluid Balance and Anion Gap
Fluid Balance
Anion Gap
Arterial Blood Gases
Assessment of Ventilatory Status
Assessment of Oxygenation Status
Limitations of Blood Gases

Oxygen Saturation Monitoring
Pulse Oximetry
Accuracy and Clinical Use of Pulse Oximetry
Limitations of Pulse Oximetry
Integrated Pulse CO-Oximetry
End-Tidal Carbon Dioxide Monitoring
Capnography
Capnography Waveforms and Clinical Application
P(a-et)CO2 Gradient
Limitations of Capnography Monitoring
Transcutaneous Blood Gas Monitoring
Transcutaneous PO2 (PtcO2)
Transcutaneous PCO2 (PtcCO2)
Cerebral Perfusion Pressure
Summary
Self-Assessment Questions
Answers to Self-Assessment Questions
References


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Chapter 10: Hemodynamic Monitoring
Introduction
Invasive Hemodynamic Monitoring
Technical Background
Units of Measurement
Types of Catheters
Arterial Catheter
Insertion of Arterial Catheter
Normal Arterial Pressure and Mean Arterial Pressure
Pulse Pressure
Potential Problems with Arterial Catheter
Central Venous Catheter

Insertion of Central Venous Catheter
Components of Central Venous Pressure Waveform
CVP Measurements
Pulmonary Artery Catheter
Insertion of Pulmonary Artery Catheter
Components of Pulmonary Arterial Pressure Waveform
PAP Measurements

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XVI

Contents

Pulmonary Capillary Wedge Pressure
Components of Pulmonary Capillary Wedge Pressure Waveform
PCWP Measurements
Verification of the Wedged Position
Cardiac Output and Cardiac Index
Summary of Preloads and Afterloads
Calculated Hemodynamic Values
Stroke Volume and Stroke Volume Index
Oxygen Consumption and Oxygen Consumption Index
Pulmonary Vascular Resistance
Systemic Vascular Resistance
Mixed Venous Oxygen Saturation
Decrease in Mixed Venous Oxygen Saturation
Increase in Mixed Venous Oxygen Saturation
Less-Invasive Hemodynamic Monitoring
Pulse Contour Analysis
Noninvasive Hemodynamic Monitoring
Transesophageal Echocardiography
#
Carbon Dioxide Elimination ( VCO2)
Impedance Cardiography
Theory of Operation
Thermodilution Method and ICG
Accuracy of ICG
Clinical Application

Summary
Self-Assessment Questions
Answers to Self-Assessment Questions
References


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Chapter 11: Ventilator Waveform Analysis
Introduction
Flow Waveforms During Positive Pressure Ventilation
Effects of Constant Flow During Volume-Controlled Ventilation
Flow-Time Waveform
Pressure-Time Waveform
Controlled Mandatory Ventilation
Assist Mandatory Volume-Controlled Ventilation
Mathematical Analysis of Constant-Flow Ventilation
Spontaneous Ventilation During Mechanical Ventilation
Synchronized Intermittent Mandatory Ventilation
Continuous Positive Airway Pressure
Effects of Flow, Circuit, and Lung Characteristics on
Pressure-Time Waveforms
Flow and Transairway Pressure
Compliance and Alveolar Pressure

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Contents

Effects of Descending Ramp Flow Waveform during
Volume-Controlled Ventilation
Time- and Flow-Limited Ventilation
Peak Flow and Tidal Volume Relationship in Time-Limited Ventilation
Effects of End-Flow on End-Transairway Pressure
Distribution of Delivered Tidal Volume
CMV during Descending Ramp Flow Ventilation
Waveforms Developed during Pressure-Controlled Ventilation
Pressure-Controlled Ventilation (PCV)
Assist Breaths during Pressure-Controlled Ventilation
Inverse Ratio Pressure-Controlled Ventilation (IRPCV)
Pressure Support and Spontaneous Ventilation
Pressure Support Ventilation (PSV)
Adjusting Rise Time during PSV
SIMV (CFW) and PSV
SIMV (DRFW) and PSV
Effects of Lung Characteristics on Pressure-Controlled

Ventilation Waveforms
Using Waveforms for Patient-Ventilator System Assessment
Patient-Ventilator Dyssynchrony
Dyssynchrony during Constant Flow Ventilation
Dyssynchrony during Descending Ramp Flow Ventilation
Changes in Pressure Waveforms during Respiratory
  Mechanics Measurement

Dyssynchrony during Pressure-Controlled Ventilation
Using Expiratory Flow and Pressure Waveforms as Diagnostic Tools
Increased Airway Resistance
Loss of Elastic Recoil
Decreased Lung-Thorax Compliance (CLT)
Gas Trapping and Uncounted Breathing Efforts
Troubleshooting Ventilator Function
Lack of Ventilator Response
Circuit Leaks
Pressure-Volume Loop (PVL) and Flow-Volume Loop (FVL)
Pressure-Volume Loop (PVL)
Effects of Lung-Thorax Compliance on PVL
Effect of Airflow Resistance on PVL
Lower Inflection Point on PVL and Titration of PEEP
Upper Inflection Point on PVL and Adjustment of VT
Effects of Airway Status on Flow-Volume Loop (FVL)
Summary
Self-Assessment Questions
Answers to Self-Assessment Questions
References
Additional Resources

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XVIII



Contents

Chapter 12: Management of Mechanical Ventilation
Introduction
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Basic Management Strategies
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Strategies to Improve Ventilation
Increase Ventilator Frequency
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Increase Spontaneous Tidal Volume or Frequency
Increase Ventilator Tidal Volume
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Other Strategies to Improve Ventilation
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Permissive Hypercapnia
Strategies to Improve Oxygenation
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Increase Inspired Oxygen Fraction (FIO2)
Improve Ventilation and Reduce Mechanical Deadspace
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Improve Circulation
Maintain Normal Hemoglobin Level
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Initiate Continuous Positive Airway Pressure (CPAP)
Initiate Positive End-Expiratory Pressure (PEEP)
383
Initiate Inverse Ratio Ventilation (IRV)
384
Initiate Extracorporeal Membrane Oxygenation (ECMO)
384

Initiate High Frequency Oscillatory Ventilation (HFOV) for Adults 385
Arterial Blood Gases
386
Respiratory Acidosis and Compensated Metabolic Alkalosis
387
Respiratory Alkalosis and Compensated Metabolic Acidosis
387
Alveolar Hyperventilation Due to Hypoxia, Improper
  Ventilator Settings, or Metabolic Acidosis


388
Alveolar Hyperventilation in Patients with COPD
388
Alveolar Hypoventilation Due to Sedation or Patient Fatigue
389
Metabolic Acid-Base Abnormalities
389
Troubleshooting of Common Ventilator Alarms and Events
389
Low Pressure Alarm
389
Low Expired Volume Alarm
390
High Pressure Alarm
391
High Frequency Alarm
391
Apnea/Low Frequency Alarm
392

High PEEP Alarm
392
Low PEEP Alarm
392
Auto-PEEP
393
Care of the Ventilator Circuit
394
Circuit Compliance
395
Circuit Patency
395
Humidity and Temperature
396
Frequency of Circuit Change
397
Care of the Artificial Airway
397
Patency of the Endotracheal Tube
397
Humidification and Removal of Secretions
398

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Contents

Ventilator-Associated Pneumonia

Fluid Balance
Distribution of Body Water
Clinical Signs of Extracellular Fluid Deficit or Excess
Treatment of Extracellular Fluid Abnormalities
Electrolyte Balance
Normal Electrolyte Balance
Sodium Abnormalities
Potassium Abnormalities
Nutrition
Undernutrition
Overfeeding
Low-Carbohydrate High-Fat Diet
Total Caloric Requirements
Phosphate Supplement
Adjunctive Management Strategies
Low Tidal Volume
Prone Positioning
Tracheal Gas Insufflation
Summary
Self-Assessment Questions
Answers to Self-Assessment Questions
References
Additional Resources


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Chapter 13: Pharmacotherapy for Mechanical Ventilation
Introduction
Drugs for Improving Ventilation
Autonomic Nervous System Agents
Adrenergic Bronchodilators (Sympathomimetics)
Anticholinergic Bronchodilators (Parasympatholytics)
Xanthine Bronchodilators
Anti-Inflammatory Agents (Corticosteroids)

Delivery of MDI Medications
Neuromuscular Blocking Agents
Mechanism of Action
Characteristics of Neuromuscular Blocking Agents
Factors Affecting Neuromuscular Blockade
Adverse Effects
Evaluation of Neuromuscular Blockade
Central Nervous System Agents
Sedatives and Antianxiety Agents (Benzodiazepines)
Opioid Analgesics
Agents for Seizures and Elevated Intracranial Pressure (Barbiturates)

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.


XX

Contents

Other Agents Used in Mechanical Ventilation
Propofol
Haloperidol
Dexmedetomidine
Nitric Oxide
Summary
Self-Assessment Questions
Answers to Self-Assessment Questions
References
Additional Resources


Chapter 14: Procedures Related to Mechanical Ventilation
Introduction
Chest Tube and Drainage System
Indications for Chest Tube
Chest Tube Selection and Placement
Methods of Placement
Chest Tube Drainage System
Care and Removal of Chest Tube
Transport with Chest Tube

Assisting in Fiberoptic Bronchoscopy
Indications for Fiberoptic Bronchoscopy
Bronchoscope and Medications
Insertion of Bronchoscope
Types of Specimen
Complications
Postbronchoscopy Care
Transport of Mechanically Ventilated Patients
Indications
Contraindications
Equipment and Supplies
Types of Transport
Procedures for Interhospital Transport
Hazards and Complications
Magnetic Resonance Imaging
Summary
Self-Assessment Questions
Answers to Self-Assessment Questions
References
Additional Resources



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Chapter 15: Critical Care Issues in Mechanical Ventilation
Introduction
Acute Lung Injury and Acute Respiratory Distress Syndrome

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.




Contents

XXI

Definitions of ALI and ARDS
Pathophysiology
Clinical Presentations
Lung Protection Using Airway Pressure Thresholds
Low Tidal Volume and Permissive Hypercapnia
Decremental Recruitment Maneuver to Determine Optimal PEEP
Prone Positioning
Ventilator-Associated Pneumonia (VAP)
Incidence of VAP
Clinical Presentations

Prevention of VAP
Treatment of VAP
Hypoxic-Ischemic Encephalopathy (Hie)
General Principles of HIE
Cerebral Perfusion Pressure
Decrease in CPP Due to Cardiac Arrest
Decrease in CPP Due to Shock
Decrease in CPP Due to Brain Injury
Evaluation and Treatment of HIE
Trauma Brain Injury
Delayed Brain Injury
Acceleration and Deceleration Brain Injuries
Clinical Evaluation and Assessment
Management Strategies
Respiratory Management
Summary
Self-Assessment Questions
Answers to Self-Assessment Questions
References

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Chapter 16: Weaning from Mechanical Ventilation
Introduction
Definition of Weaning Success and Failure
Weaning Success
Weaning in Progress
Weaning Failure
Patient Condition Prior to Weaning
Weaning Criteria
Ventilatory Criteria
Oxygenation Criteria

Pulmonary Reserve
Pulmonary Measurements
Rapid Shallow Breathing Index (Rsbi)
Weaning Procedure
Spontaneous Breathing Trial

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.


XXII

Contents

Failure of SBT

Pressure Support Ventilation
Other Modes of Partial Ventilatory Support
Weaning Protocol
Signs of Weaning Failure
Causes of Weaning Failure
Increase of Airflow Resistance
Decrease of Compliance
Respiratory Muscle Fatigue
Terminal Weaning
Prior to Withdrawal
Withdrawal
Summary
Self-Assessment Questions
Answers to Self-Assessment Questions
References
Additional Resources


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542

Chapter 17: Neonatal Mechanical Ventilation
Introduction
Intubation
Indications
Equipment
Surfactant Replacement Therapy
History
Indications
Types of Surfactant and Dosages
Outcomes
Nasal CPAP
Use of Nasal CPAP
Basic Principles of Neonatal Ventilation
Pressure-Controlled Ventilation
Volume-Controlled Ventilation
Ventilator Circuits and Humidifiers
Initiation of Neonatal Ventilatory Support
Indications for Mechanical Ventilation
Initial Ventilator Settings
High Frequency Ventilation (HFV)
High Frequency Positive Pressure Ventilation (HFPPV)
High Frequency Jet Ventilation (HFJV)
High Frequency Oscillatory Ventilation (HFOV)
Initial HFOV Settings

Other Methods of Ventilation
Machine Volume

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Copyright 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.


Contents

Volume Guarantee
Liquid Ventilation
Extracorporeal Membrane Oxygenation (ECMO)
History
Patient Selection
ECMO Criteria
Mechanisms of Bypass
Complications
Summary
Self-Assessment Questions
Answers to Self-Assessment Questions
References
Additional Resources


XXIII

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Chapter 18: Mechanical Ventilation in Nontraditional Settings
Introduction
Mechanical Ventilation at Home
Goals of Home Mechanical Ventilation (HMV)
Indications and Contraindications
Patient Selection
Equipment Selection
Mechanical Ventilation in Mass Casualty Incidents
Causes of Mass Casualty
Mass Casualty and Mechanical Ventilation
Triage Systems for Mass Casualty Incidents
Strategic National Stockpile
Exclusion Criteria for Mechanical Ventilation
Personnel and Planning
Mechanical Ventilation in Hyperbaric Condition
Rationale for Hyperbaric Oxygenation (HBO)
Indications for HBO
Endotracheal Tube and Ventilator
Tidal Volume Fluctuations
Monitoring and Mechanical Ventilation
Defibrillation and Cardiac Pacing
Mechanical Ventilation in Hypobaric Condition
High-Altitude Cerebral and Pulmonary Edema
Airplane Cabin Pressure

Ventilator Parameter Changes under Hypobaric
  Conditions
Pressure Compensation
Traveling with Portable Ventilators
Characteristics of Portable Ventilators
Traveling in the United States

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Copyright 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.