Section Editor: Norig Ellison
Book and Multimedia Reviews
Principals and Practices of
Mechanical Ventilation,
2nd ed.
Tobin MJ, ed. New York: McGraw-Hill,
2006. ISBN 0-07-1447676-9. 1442 pages,
$189.00.
ccording to Dr. Tobin, the Principals
A and Practices of Mechanical Ventilation
when combined with its companion text
Downloaded from http://journals.lww.com/anesthesia-analgesia by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 07/27/2021
Principals and Practices of Intensive Care
Monitoring incorporates “the unique cor-
pus of knowledge required for expert
practice for intensive care medicine . . .”
Although the latter has not been re-
viewed, the current text certainly is com-
prehensive in its mention of every
conceivable ventilatory technique. In the
12 years since the first publication of the
text, many new aspects regarding treat-
ment of severe lung failure and several
new modes of ventilation, not mentioned
in the previous text, have arisen.
The text consists of 70 chapters and
106 authors from 13 different countries.
Tobin’s editorial efforts are very appar-
ent with a remarkable uniformity from
chapter to chapter. A review of various
chapters lends sad commentary with
respect to innovations emanating from
the United States, especially with re-
gard to anesthesiology. Only 54 of the
106 authors are from the United States
and only 16, two of whom are from the
United States, have a listed connection
with anesthesiology. Those two anesthe-
siologists authored the chapter “Airway
Management.” Six surgeons contributed
to the text. Therefore, there is a distinct
bias toward medical/CCM versus
surgical/CCM, which many would sug-
gest is a meaningless distinction. How-
ever, there are several areas where this is
apparent. There are only a few paragraphs
devoted to postsurgical pulmonary
complications, atelectasis, respiratory
failure, and mechanical ventilatory sup-
port. In fact, there is no significant
discussion of the appropriate manage-
ment of these patients with respect to
monitoring, weaning, etc., although the
volume of postsurgical patients venti-
lated in most hospitals at any given
time probably exceeds those treated in
medical/pulmonary/cardiac intensive
care areas. Furthermore, there is no
mention of the appropriate ventilatory
management of anesthetized patients.
This void leaves the reader with no
information regarding intraoperative
Vol. 104, No. 2, February 2007
recruitment maneuvers or the appro-
priate use of positive end-expiratory
pressure, intraoperatively.
Intermittent mandatory ventilation,
arguably the most commonly used
technique in postoperative patients, es-
pecially in conjunction with pressure
support ventilation, is presented in a
negative light, with most of 19 pages
devoted to debunking claims of advan-
tages of spontaneous breathing. In con-
trast, the chapter on airway pressure
release ventilation (APRV) was written
by an individual with considerable
research and clinical experience with
the technique. A review of this well-
written chapter leaves the reader won-
dering why one would use any other
ventilatory technique in treating the
ventilator-dependent patient. Interest-
ingly, a table listing modes of ventila-
tion available on selected ventilators
incorrectly lists only one device that has
APRV, although many ventilators have
this feature. The text also incorrectly
identifies “bilevel” airway pressure as
an “improvement” of APRV, a state-
ment that in this reviewer’s opinion is
inaccurate.
A three-page discussion of heart-
lung interaction is approached primar-
ily from the standpoint of the patient
with respiratory muscle dysfunction,
weakness, and/or congestive heart fail-
ure. Therefore, spontaneous ventilation
is presented in a negative light and
positive pressure ventilation as sup-
portive of cardiac function. There is
little mention of the supportive role that
spontaneous breathing with continuous
positive airway pressure may play in
this regard, except to say “all these
(beneficial) effects can be achieved in
non-intubated patients using non-
invasive mask CPAP and BiPAP.” Once
again, this chapter contrasts distinctly
with the chapter on APRV.
As an anesthesiologist, this reviewer
was interested to find 15 pages devoted
to pain control, sedation, and paralysis.
Most of the chapter was devoted to
available drugs, dosages, and routes of
administration. Essentially, the chapter
presents a short course on the adminis-
tration of anesthesia without the monitor-
ing that would occur in the operating
room environment.
Weaning is approached from the
standard aspect of the patient with
long-term ventilator dependence. Al-
though the editor has long been recog-
nized as the preeminent clinical expert
in this area, he fails to separate “wean-
ing” into the essential components of
oxygen dependence, CPAP depen-
dence, and ventilator dependence. Fail-
ure to approach these areas separately
inevitably will lead to prolonged venti-
lator care. To the editor’s credit, the
distinction between “weaning” and
“tracheal extubation” is emphasized by
devoting a full chapter to the latter
topic.
Finally, kudos to the editor for chap-
ter 67 “Interpreting Clinical Trials of
Mechanical Ventilation: The Impor-
tance of Routine Care,” by Deans and
other colleagues of Peter Eichacker and
his team at NIH. They present a contro-
versial and accurate analysis of data,
which may be extremely relevant to our
specialty. There is a current push to
decrease tidal volume of anesthetized
patients, on the basis of an extrapola-
tion of data from the ARDS Net trial.
Eichacker presents evidence to suggest
that patients with a respiratory system
compliance greater than 0.6 mL/kg
(which includes most of our patients)
do better with a larger tidal volume
(8 –10 mL/kg) and less well with a tidal
volume of 6 mL/kg.
In summary, the editor has succeeded
in presenting a well-balanced textbook
that offers information on every aspect
on mechanical ventilation outside of the
operating room. Hopefully, we will have
advanced knowledge regarding ventila-
tion of the anesthetized patient to a point
sufficient to justify inclusion of that sub-
ject in the next edition.
John B. Downs, MD
Department of Anesthesiology
University of Florida
Tampa, FL
jdowns@health.usf.edu
Qbase Anaesthesia, Vol. 5:
MCQ’s for the Final FRCA
Hammond E, McIndoe AK, eds. New
York: Cambridge University Press,
2006. ISBN 0-521-67705-X. 211 pages ⫹
CD-ROM, $50.00.
he Royal College of Anaesthetists,
T the professional body responsible for
the specialty of anesthesia throughout the
United Kingdom, includes a 90-question
multiple choice test as part of its final
fellowship examination. This book, in-
tended as a study guide in preparation
for the FRCA (Fellowship of the Royal
College of Anaesthetists), is designed for
the physician preparing for this test. The
book includes well-written questions
473
Book and Multimedia Reviews
with explanations on a broad range of
topics in anesthesia.
The book includes five tests, each
with 60 questions. Each question is
structured as a five-part true-and-false,
with penalties for answering questions
incorrectly. An answer key (with expla-
nations) then follows at the end of each
test. Additionally, a CD-ROM is pro-
vided to facilitate self-testing and evalu-
ation. The CD-ROM includes the same
questions as the book, with an additional
option to help a test taker determine an
optimal selection strategy.
Most other board review books (like
those by Hall and Chu) have been de-
signed with the frequently recurring top-
ics on the American boards in mind,
making them high-yield reviews for
American students of anesthesia. This
book has been designed with a similar
purpose, but for the British board exams.
The topics do generally mirror those of
the American test, with normal physiol-
ogy, pathophysiology, machines, cardiol-
ogy, obstetrics, pain, regional, physics,
and pharmacology all well represented.
Pediatrics is somewhat underempha-
sized on these tests compared with the
American test. Generally, the book’s
questions focus more on minutiae than
the American test, with detailed ques-
tions about topics such as E.coli and
xenon.
The structure is entirely different
from that of the American written
board exam, which is composed en-
tirely of multiple-choice and “K-type”
questions. In addition, many of the
questions in “Qbase” use terms, spell-
ings, and names unfamiliar to Ameri-
can test takers. This tends to make the
questions difficult to follow at best, and
at worst virtually useless for prepara-
tion for American boards. For example,
the book commonly refers to named
devices and techniques that are seldom
mentioned in literature familiar to
American residents (such as the Bene-
dict Roth spirometer or the Bryce-Smith
tube). It features questions on drugs
that have fallen out of favor in the
United States, such as enflurane, and on
tests and algorithms that are rarely
used in the Unite States, such as the
Goldman cardiac risk index, even
though the index was developed in
America.
This is not to say the book is badly
written; on the contrary, it does have
value as a clinical review for an anes-
thesia practitioner. The reader would
need to briefly evaluate each question
to determine whether it is relevant to
practice in the United States (about
15%–20% of the questions are probably
too based in U.K. terminology to be
useful). The questions cover a broad
variety of topics and each question
474 Book and Multimedia Reviews
comes with a thorough explanation of
the reasoning behind the answers.
However, this reviewer cannot recom-
mend this book for written board
preparation for a student taking the
American anesthesia boards.
Jason Fehr, MD
Department of Anesthesiology and
Critical Care
University of Pennsylvania
Philadelphia, PA
fehrj@uphs.upenn.edu
The Structured Oral
Examination Practice Papers
for Teachers and
Trainees-Primary FRCA
Balasubramanian S, Mendonca C,
Pinnock C, eds. Cambridge, UK: Cam-
bridge University Press, 2006. ISBN
0-521-68050-6. 262 pages, $55.00.
ow can those who teach anesthesi-
H ology be sure that graduate medi-
cal trainees are competent? How can
those who are responsible for creden-
tialing practitioners to care for patients
certify specialty status of anesthesiolo-
gists? The answers to these questions
are vital to the educational process for
specialists in anesthesiology to assure
the public trust when seeking anes-
thesia patient care.
The oral examination of the Royal
College of Anaesthetists (UK) has as
one of its goals providing answers to
questions about practitioner certifica-
tion. The Royal College of Anaesthetists
states that it exists for:
“The setting of standards for practice
in anaesthesia, establishing the standards
for the training of anaesthetists and those
practising critical care and/or acute and
chronic pain management, setting and
running examinations, and the continued
medical education of all practising anaes-
thetists.” (http://www.rcoa.ac.uk/index.
asp?PageID⫽1. Accessed 09/13/2006.)
It would be ideal if a text existed that
would teach anesthesiology graduate
trainees and their teachers how to ap-
proach and master the oral examination
portion of the certifying examination to
achieve the Royal College goals and
demonstrate competence.
The Structured Oral Examination [SOE]
Practice Papers for Teachers and Trainees-
Primary FRCA is a new offering de-
signed to accomplish this task. The
publisher touts this as a, “. . . book
. . . made up of questions and answers
that closely simulate the Royal College
of Anaesthetists’ oral examination for-
mat. Set up as complete examination
papers, the book enables candidates to
assess their knowledge accurately and
within time limits.”
The authors have succeeded in pre-
senting questions, answers, and an un-
derstanding of the Royal College oral
examination format. Ten SOEs are
available for review. Each includes
questions and “model answers” in four
major content areas (physiology; phar-
macology; clinical; and physics, clinical
measurement, and safety). Within each
major area, a broad list of specific “key
topics” is considered in depth. The ma-
jor strength of this text is its broad and
in-depth consideration of the content of
anesthesiology.
Mastery of the content of anesthe-
siology, however, does not insure
competence in our specialty nor is it
sufficient for certification of practitio-
ners. Anesthesiologists must be able
to judge alternative approaches to pa-
tient care and communicate effec-
tively with other physician colleagues
and paraprofessional staff within the
hospital. The oral examination enables
and requires candidates to display their
prowess in more than recitation of
knowledge. Being able to recognize that
a Board Certification candidate can de-
velop a patient problem list, prioritize
these issues, and articulate a primary
care plan and a “plan B” to use when
patients behave differently than what
the books say is essential for meaning-
ful certification of specialists.
SOE is a text that is right on target,
presenting a broad base of knowledge
of anesthesiology. SOE has missed the
mark in not explicitly considering, for
teachers and trainees, how to apply
knowledge, communicate appropriate
clinical judgment, organize medical
knowledge, and present an anesthesia
patient care plan in a clearly articu-
lated manner.
The authors of SOE have an oppor-
tunity for its next edition to address
what virtually no other “Board Prep”
book has. Adding a chapter that will
explain the process issues in education
will enable Board Certification candi-
dates (future practitioners) and their
teachers to make much better use of the
content, ensuring a valid certification
examination ultimately benefiting anes-
thesia patient care.
Alan Jay Schwartz, MD, MSed
Director of Education
Department of Anesthesiology and Critical
Care Medicine
Program Director, Pediatric Anesthesiology Fellowship
The Children’s Hospital of Philadelphia
Clinical Professor of Anesthesiology and Critical Care
University of Pennsylvania
Philadelphia, PA
schwartza@email.chop.edu
ANESTHESIA & ANALGESIA