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RespiRatoRy CaRe
Third Edition
Robert L. Chatburn, MHHS, RRTNPS, FAARC
Clinical Research Manager
Respiratory Institute
Cleveland Clinic
Adjunct Associate Professor
Department of Medicine
Lerner College of Medicine of Case Western Reserve University
Cleveland, Ohio
Eduardo MirelesCabodevila, MD
Director
Medial Intensive Care Unit
Assistant Professor
Division of Pulmonary and Critical Care Medicine
University of Arkansas for Medical Sciences
Little Rock, Arkansas
84096_FMXX_Chatburn.indd 1 6/17/10 1:35:15 PM
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Library of Congress CataloginginPublication Data
Chatburn, Robert L.
Handbook of respiratory care / Robert L. Chatburn, Eduardo MirelesCabodevila.  3rd ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 9780763784096 (pbk. : alk. paper)
1. Respiratory therapyHandbooks, manuals, etc. I. MirelesCabodevila, Eduardo. II. Title.
[DNLM: 1. Respiratory TherapyHandbooks. WF 39 C492h 2011]
RC735.I5L68 2011
616.2’0046dc22
2010023519
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Dedication
I would like to dedicate this book to three people. First is my daughter Maya, who has taught
me how strength of spirit can carry you through any adversity. Second is my daughter Kendra,
who has taught me that our world needs better planners who are inspired by a vision for social
justice. Third is my mentor at the Cleveland Clinic, Dr. James K. Stoller, who taught me that
faith in people is better than the “carrot or the stick.”
RLC
To Marina, my wife, who endures, loves, guides, and nurtures. To my parents, Mario and Cristi,
who taught me that it is not what they give you, it is what you do with it. To my sisters, for their
persistence and joy. To my mentors, who had faith in me, and hopefully will never need to use the
stick.
EMC
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Intentional Blank x
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CONTENTS
CONTENTS
Preface ix
ChaPter 1 Scores and Definitions Used in Respiratory and
Critical Care Research 1
Charlson Comorbidity Index 2
McCabe Classification 2
The Knaus Chronic Health Status Score 3
Glasgow Coma Scale 3
Trauma Score 4
Revised Trauma Score (RTS) 4
Pediatric Trauma Score 5
Injury Severity Score (ISS) 5
TraumaInjury Severity Score (TRISS) 6
Acute Physiology and Chronic Health Evaluation (APACHE II) 6
Sequential Organ Failure Assessment (SOFA) Score 6
Multiple Organ Dysfunction (MOD) Score 11
Simplified Acute Physiology Score (SAPS II) and Expanded Version 12
Pediatric Risk of Mortality (PRISM) 14
Pediatric Index of Mortality II (PIM II) 15
Apgar Score 16
Silverman Score 17
Newborn Respiratory Distress Scoring (RDS) System 18
Sepsis Definition 18
2001 Expanded Diagnostic Criteria for Sepsis 20
Vasopressor Score (Inotropic Score, Cathecholamine Index) 21
Acute Respiratory Distress Syndrome Definition 21
Lung Injury Score (Murray Score) 21
VentilatorFree Days 22
Pneumonia Definitions 22
Clinical Pulmonary Infection Score 24
Definitions for Weaning and Liberation of Mechanical Ventilation 25
Intubation Difficulty Scale 26
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vi  Contents
Wells Score: Pulmonary Embolism 26
Wells Score: Deep Vein Thrombosis (DVT) 28
ChaPter 2 Pulmonary Function 31
Kevin McCarthy, RPFT
Spirometry 33
Bronchial Inhalation Challenges 41
Exercise Physiology 42
ChaPter 3 Physiologic Monitoring 47
Gas Exchange 48
BloodGas Analysis: Traditional and the Stewart Method 73
Hemodynamics 84
ChaPter 4 Gas Therapy 97
The General Gas Law 98
Special Gas Laws 99
Oxygen Administration 113
Gas Cylinders 117
ChaPter 5 Mechanical Ventilation 127
Airways 128
Definition of Terms 132
Classifying Modes of Mechanical Ventilation 156
Mathematical Models of PressureControlled Mechanical
Ventilation 163
ChaPter 6 Mathematical Procedures 167
Fundamental Axioms 168
Fractions 169
Ratios, Proportions, and Unit Conversion 173
Exponents 174
Scientific Notation 174
Significant Figures 176
Functions 178
Quadratic Equations 180
Logarithms 182
Trigonometry 186
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Contents  vii
Probability 188
Statistical Procedures 190
Mathematical Signs and Symbols 195
The Greek Alphabet 196
Random Numbers 196
SI Units 198
Definitions of Basic Units 202
Physical Quantities in Respiratory Physiology 203
aPPenDix Reference Data 209
Clinical Abbreviations 210
Physiological Abbreviations 211
BloodGas Measurements 216
Basic Pharmacological Formulas and Definitions 217
Miscellaneous Reference Data 220
Translation of Commonly Used Words 235
Postural Drainage Positions 246
Index 253
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Intentional Blank x
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PREFACE
PREFACE
It has been 23 years since the First Edition of the Handbook of Respiratory
Care, and 10 years since our last edition. During this period much has
changed in the field of respiratory care, including advances in ventilation
equipment, the development of evidencebased medicine, the universal pres
ence of computers and the Internet in health care, and the standardization
of nomenclatures and definitions. Yet much has not changed. Research and
clinical practice still requires a reference standard, a source to obtain basic
data that serves as foundation to research and clinical practice.
The Handbook of Respiratory Care is intended for both practicing cli
nicians and students wishing to have a summary of data not found in other
textbooks. It is also intended for the clinician or researcher while reading an
article, formulating research, or providing patient care. This edition has been
adapted to be a companion of the contemporary clinician in the Internet era.
Indeed, we now can obtain much information from the Internet; however,
the Handbook represents years of collection of specific data that is not uni
versally available. Nonetheless, it must be understood that this compilation,
although intended to be global, is subject to change according to geographi
cal location and practice variation.
The new edition was extensively revised to reflect current clinical needs
in practice and research. We have devoted the first chapter to the most com
monly used scores and definitions in respiratory and critical care research.
Our goal is for the reader to have the ability to easily find what each score
or definition entails and how it is calculated. It should also help as a starting
point, as a source tool when attempting to design research. The pulmonary
function chapter, Chapter 2, has been revised by Kevin McCarthy to reflect
the recent changes in prediction equations in pulmonary function and exer
cise physiology. The chapters on physiology, gas therapy, and mathematical
procedures were revised and updated. We added new concepts in physiology
and acid–base physiology. All the chapters have new and easier to use tables,
figures, and nomograms. The mechanical ventilation chapter now includes a
simpletouse method to classify and understand all the modes of mechani
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x  Preface
cal ventilation. Finally, the appendix has grown in size and scope and now
includes a collection of difficulttofind concepts, figures, and classifications.
The Handbook of Respiratory Care compiles a wide variety of data
from many sources in the fields of medicine, physics, mathematics, and engi
neering. It has been said that the key to knowledge is not in how many facts
one may have memorized, but in knowing where to find them when needed.
It is in this spirit that the Third Edition of the Handbook of Respiratory Care
has been written. It is our hope that this edition becomes a good companion
to the respiratory care clinicians and students attempting to navigate the
overwhelming sea of information available.
RLC
EMC
Contributing Author ■
Kevin McCarthy, RPFT
Technical Director/Manager
Pulmonary Function Laboratories
Cleveland Clinic, Respiratory Institute
Cleveland, Ohio
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CHAPTER
1
CHAPTER
1
Scores and
Definitions Used
in Respiratory
and Critical Care
Research
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2  CHAPTER 1 Scores and Definitions
Current articles use several scores and definitions to describe the population
being studied. We present the scores as well as the original source. We also
include the latest consensus in some definitions used in respiratory and criti
cal care.
Charlson Comorbidity index ■
Method for classifying comorbid conditions that might alter the risk of mor
tality for use in longitudinal studies. The oneyear mortality rates for the
different scores were 0: 12%; 1–2: 26%; 3–4: 52%; and greater than or equal
to 5: 85%. The predicted risk of death from comorbid disease at a 10year
followup is 0: 8%; 1: 25%; 2: 48%; and greater than or equal to 3: 59%.
Assigned weight for each patient’s condition. The total equals the score.
1 point: Myocardial infarct, Congestive heart failure, Peripheral vascular
disease, Cerebrovascular disease, Dementia, Chronic pulmonary dis
ease, Connective tissue disease, Ulcer disease, Mild liver disease, and
Diabetes
2 points: Hemiplegia, Moderate or severe renal disease, Diabetes with
endorgan damage, Any tumor, Leukemia, and Lymphoma
3 points: Moderate or severe liver disease
6 points: Metastatic solid tumor, and AIDS
Data from Charlson, M. E. et al. J Chronic Dis 40 (1987), 373–383.
mCCabe ClassifiCation ■
Classification generated to obtain comparisons regarding the importance of
host factors based on the severity of the underlying disease. In parentheses
we give the disease examples from the original article (McCabe, W. R. and
Jackson, G. G. Arch of Int Med 110 (1962), 847–891). Evidently the progno
sis for some has changed.
Category 1: Nonfatal disease (diabetes, genitourinary, gastrointestinal or
obstetrical conditions)
Category 2: Ultimately fatal disease (diseases estimated to become fatal
within 4 years, e.g., aplastic anemia, metastatic carcinomas, cirrhosis,
chronic renal disease)
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Glasgow Coma Scale  3
Category 3: Rapidly fatal disease (acute leukemia, blastic relapse of
chronic leukemia)
the Knaus ChroniC health status sCore ■
Score used in the original APACHE article, and now used to describe base
line health status of the patients enrolled in studies.
Class A: Normal health status
Class B: Moderate activity limitation
Class C: Severe activity limitation due to chronic disease
Class D: Bedridden patient
Data from Knaus et al. Crit Care Med 9(8) (1981), 591–597.
GlasGow Coma sCale ■
(See Table 1–1.) Scale used to describe the neurological status of a patient,
the neurological prognosis, and levels of brain injury. Points are added for
each section.
Table 1–1 Glasgow Coma Scale
Points
Eye opening Spontaneous 4
To voice 3
To pain 2
None 1
Verbal response Oriented 5
Confused 4
Inappropriate words 3
Incomprehensible words 2
None 1
Motor response Obeys commands 6
Localizes 5
Withdraws 4
Flexion (decorticate) 3
Extension (decerebrate) 2
None 1
Data from Teasdale, G. M. and Jennet, B. Lancet 304 (1974), 81–84.
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4  CHAPTER 1 Scores and Definitions
trauma sCore ■
(See Table 1–2.) A field scoring system in which values are correlated with
probability of survival. Points are added from each category. A score of 1–5
points has a probability of survival of 0%; 6–7 points, 10%; 8–9 points, 22 to
37%; 10 points, 55%; 11 points, 71%; 12 points, 83%; and above 13 points,
90%.
revised trauma sCore (rts) ■
(See Table 1–3.) A revised form of the trauma score used by the Trauma
Injury Scoring System (TRISS). It only uses three categories, for which a
value is assigned. Each category value is multiplied by an assigned category
weight, and the resultant values for each category are then added to obtain
the RTS.
Table 1–2 Trauma Score
Points 4 3 2 1 0
Respiratory Rate 10–24 25–35 .35 ,10 Apnea
Respiratory Effort Normal Shallow or
retractions
Systolic Blood Pressure .90 70–90 50–69 ,50 Not palpable
Capillary Refill Normal Delayed None
Glasgow Coma Scale 14–15 11–13 8–10 5–7 3–4
Data from Champion, H. R. et al. Crit Care Med 9 (1981), 672–676.
Table 1–3 Revised Trauma Score (RTS)
Points 4 3 2 1 0 Value Weight
*
Final
Value
Respiratory
Rate
10–29 .29 6–9 1–5 0 0.2908
Systolic Blood
Pressure
.89 76–89 50–75 1–49 0 0.7326
Glasgow Coma
Scale
13–15 9–12 6–8 4–5 3 0.9368
*
Multiply Value by Weight to get Final Value. Add all final values to obtain RTS scores.
Adapted from Champion, H. R. et al. J Trauma 29(5) (1989), 623–629.
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Injury Severity Score (ISS)  5
PediatriC trauma sCore ■
(See Table 1–4.) A score used to predict injury severity in pediatric patients.
The sum of the points correlates with survival. Scores greater than 8 had a
0% mortality; between 0 and 8 had an increasing mortality. Scores below 0
had 100% mortality.
injury severity sCore (iss) ■
An anatomical scoring system that provides an overall score for patients with
multiple injuries (Baker, et al. J Trauma 14 (1974), 187–196). Each injury
is assigned an Abbreviated Injury Scale (AIS) score, allocated to one of six
body regions (head, face, chest, abdomen, extremities, and external). Only
the highest AIS score in each body region is used. The three most severely
injured body regions have their score squared and added together to produce
the ISS score.
The AIS ranges from 0 to 6, 0 being no injury, and 6 unsurvivable injury.
The ISS values range from 0 to 75. A patient with an ISS score of 6 in any
category automatically obtains the maximum ISS score (75). The AIS scores
used are revised and published by the Association for the Advancement of
Automotive Medicine.
Table 1–4 Pediatric Trauma Score
Points +2 +1 1
Size .20 kg 10–20 kg ,10 kg
Airway Normal Maintainable Unmaintainable
Systolic Blood Pressure
or Pulse
.90 mmHg
Pulse palpable
wrist
50–90 mmHg
Pulse palpable
groin
,50 mmHg
No pulse
palpable
Mental Status Awake Obtunded Coma/
Decerebrate
Skeletal None Closed fracture Open/Multiple
fractures
Cutaneous None Minor Major/
Penetrating
Adapted from Tepas, J. J. et al. J. Trauma 38 (1988), 425–429.
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6  CHAPTER 1 Scores and Definitions
traumainjury severity sCore (triss) ■
A score that uses values from the ISS, the RTS, the patient age, and the type
of injury to quantify the probability of survival (Boyd, C. R. et al. J Trauma
27(4) (1987), 370–378).
Age points: $55 years old = 1 point, otherwise 0 points.
TRISS (blunt): b = 20.4499 + RTS 3 0.8085 +
ISS 3 20.0835 + (age points) 3 21.7430
or
TRISS (penetrating): b = 22.5355 + RTS 3 0.9934 +
ISS 3 20.0651 + (age points) 3 21.1360
then
Probability of survival = 1/(1 + e
b
)
Probability of death = 1 – probability of survival.
aCute PhysioloGy and ChroniC health ■
evaluation (aPaChe ii)
(See Tables 1–5 and 1–6.) Used as a clinical scoring system to classify the
severity of illness. APACHE II uses the worst last values in the last 24 hours.
To calculate the predicted death rate:
APACHE II SCORE = Acute Physiology Score + Age points + Chronic
Health points
Ln (R/1 2 R) = 23.517 + ( Apache II) * 0.146 + Diagnostic Category
Weight + 0.603 if postemergency surgery.
Predicted Death Rate = e
Ln (R/1 2 R)
/(1 + e
Ln (R/1 2 R)
) where “e” is the base
of natural logarithm, 2.718.
sequential orGan failure assessment ■
(sofa) sCore
(See Table 1–7.) Score designed to describe the degree of organ dysfunction
in critically ill patients.
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Acute Physiology and Chronic Health Evaluation (APACHE II)  7
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8  CHAPTER 1 Scores and Definitions
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84096_CH01_Chatburn.indd 8 6/16/10 6:31:44 AM
Acute Physiology and Chronic Health Evaluation (APACHE II)  9
Table 1–6 Diagnostic Categories Weight Leading to ICU Admission (APACHE II)
Nonoperative
Respiratory Failure Trauma
Asthma/allergy 22.108 Multiple trauma 21.228
COPD 20.367 Head injury 20.517
Pulmonary edema (non cardiogenic) 20.251 Neurologic
Postrespiratory arrest 20.168 Seizure disorder 20.584
Aspiration/poisoning/toxic 20.142 ICH/SDH/SAH 0.723
Pulmonary embolus 20.128 Other
Infection 0 Drug overdose 23.353
Neoplasm 0.891 Diabetic ketoacidosis 21.507
Cardiovascular Failure GI Bleeding 0.334
Hypertension 21.798 If Not in One of These Groups,
What System Was the Principal
Reason for Admission?
Rythm disturbance 21.368
Congestive heart failure 20.424
Hemorrhagic shock/hypovolemia 0.493
Coronary artery disease 20.191 Metabolic/renal 20.885
Sepsis 0.113 Respiratory 20.890
Post cardiac arrest 0.393 Neurologic 20.759
Cardiogenic shock 20.259 Cardiovascular 0.470
Dissecting thoracic/
abdominal aneurysm
0.731 Gastrointestinal 0.501
Postoperative
If Postemergency Surgery
Multiple trauma 21.684 21.081
Admission due to chronic cardio
vascular disease
21.376 20.773
Peripheral vascular surgery 21.315 20.712
Heart valve surgery 21.261 20.658
Craniotomy for neoplasm 21.245 20.642
Renal surgery for neoplasm 21.204 20.601
Renal transplant 21.042 20.439
Head trauma 20.955 20.352
Thoracic surgery for neoplasm 20.802 20.199
Craniotomy for ICH/SDH/SAH 20.788 20.185
Laminectomy and other spinal cord
surgery
20.699 20.096
Hemorrhagic shock 20.682 20.079
(continued)
84096_CH01_Chatburn.indd 9 6/16/10 6:31:44 AM
10  CHAPTER 1 Scores and Definitions
Table 1–6 Diagnostic Categories Weight Leading to ICU Admission (APACHE II cont.)
Postoperative
If Postemergency Surgery
GI bleeding 20.617 20.014
GI surgery for neoplasm 20.248 0.355
Respiratory insufficiency 20.140 0.463
GI perforation/obstruction 0.060 0.663
If Not in One of the Above, What System Led to ICU Admission Postsurgery?
Neurologic 21.150 20.574
Cardiovascular 20.797 20.194
Respiratory 20.610 20.007
Gastrointestinal 20.613 20.01
Metabolic/renal 20.196 0.407
Adapted from Knaus, W. A. et al. Crit Care Med 13 (1985), 818–829.
Table 1–7 Sequential Organ Failure Assessment (SOFA) Score
Points 1 2 3 4
Respiration
Pao
2
/Fio
2
, mmHg
,400 ,300 ,200 ,100
Coagulation
Platelets 3 10
3
/mm
3
,150 ,100 ,50 ,20
Liver
Bilirubin, mg/dl
1.2–1.9 2.0–5.9 6.0–11.9 .12
Cardiovascular
Hypotension
*
MAP ,70 Dopamine
#5 or dobu
tamine (any
dose)
Dopamine
.5 or epi
nephrine
#0.1 or nor
epinephrine
#0.1
Dopamine
.15 or
epinephrine
.0.1 or nor
epinephrine
.0.1
Central Nervous
System
Glasgow Coma Score
13–14 10–12 6–9 ,6
Renal
Creatinine mg/dl or
Urine Output
1.2–1.9 2.0–3.4 3.5–4.9 or
,500 mL/
day
.5 or ,200
mL/day
*
Vasopressors agents administered for at least 1 hr (mg/kg·min)
Adapted from Vincent, J. L. et al. Int Care Med 22 (1996), 707–710.
84096_CH01_Chatburn.indd 10 6/16/10 6:31:45 AM
Multiple Organ Dysfunction (MOD) Score  11
Table 1–8 Multiple Organ Dysfunction Score
Organ System 0 1 2 3 4
Respiratory Pao
2
/Fio
2
.300 226–300 151–225 76–150 #75
Renal
Serum creatinine mmol/L
(mg/dl)
#100
(1.1)
101–200
(1.1–2.3)
201–350
(2.3–4)
351–500
(4–5.7)
.500
(5.7)
Liver
Serum bilirubin mmol/L
(mg/dl)
#20
(1.2)
21–60
(1.2–3.5)
61–120
(3.6–7)
121–240
(7.1–14)
.240
(14)
Cardiovascular
Pressureadjusted heart
rate
*
#10 10.1–15 15.1–20 20.1–30 .30
Hematologic
Platelet count mL 10
23
.120 81–120 51–80 21–50 #20
Neurologic Glasgow coma
score
**
15 13–14 10–21 7–9 #6
*
Pressureadjusted heart rate = (heart rate 3 right atrial pressure)/mean arterial pressure.
**
For patients receiving sedation or muscle relaxants normal brain function is assumed unless there is evidence
of altered mentation.
MOD
Score
Intensive Care
Unit Mortality
Hospital
Mortality
Intensive Care
Unit Stay (days)
0 0% 0% 2
1–4 12% 7% 3
5–8 35% 16% 6
9–12 25% 50% 10
13–16 50% 70% 17
17–20 75% 82% 21
21–24 100% 100% n.a.
Adapted from Marshall, J. C. et al. Crit Care Med 23 (1995), 1638–1652.
multiPle orGan dysfunCtion (mod) sCore ■
(See Table 1–8.) Score designed to describe the degree of organ dysfunction
in critically ill patients. It correlates with intensive care and hospital mortal
ity and intensive care unit length of stay as originally described.
84096_CH01_Chatburn.indd 11 6/16/10 6:31:45 AM
12  CHAPTER 1 Scores and Definitions
Table 19 Simplified Acute Physiology Score (SAPS II) and Expanded Version
SAPS II 0 points Abnormal value points
Age, years ,40 40–59
7 points
60–69
12 points
70–74
15 points
75–79
16 points
$ 80
18 points
Heart rate, beats/min 70–119 40–69
2 points
120–159
4 points
$ 160
7 points
, 40
11 points
Systolic Blood Pressure,
mmHg
100–199 .200
2 points
70 –99
5 points
# 70
13 points
Body Temperature, °C ,39 $ 39
3 points
Only if on Mechanical
Ventilation* Pao
2
mmHg/
Fio
2
$ 200
6 points
100–199
9 points
,100
11 points
Urinary Output, L/day $ 1 0.5–0.9
4 points
, 05
11 points
Blood Urea Nitrogen,
mg/dL
,28 28–83
6 points
$ 84
10 points
White Blood Cell Count,
mm
3
1–19.9 $ 20
3 points
, 1.0
12 points
Potassium, mEq/L 3–4.9 , 3 or
$ 5
3 points
Sodium, mEq/L 125–144 $145
1 point
, 125
5 points
Bicarbonate, mEq/L $20 15–19
3 points
, 15
6 points
Bilirubin, mg/dl ,4 4–5.9
4 points
$ 6
9 points
Glasgow Coma Score 14–15 11–13
5 points
9 – 10
7 points
6 – 8
13 points
,6
26 points
simPlified aCute PhysioloGy sCore (saPs ii) ■
and exPanded version
(See Table 1–9.) Score to calculate to probability of hospital mortality. The
score revised in 2005 is referred to as the expanded version. The score uses
the worst value (the one that gives the most points) in last 24 hours.
(continued)
84096_CH01_Chatburn.indd 12 6/16/10 6:31:45 AM
Simplified Acute Physiology Score (SAPS II) and Expanded Version  13
Table 19 Simplified Acute Physiology Score (SAPS II) and Expanded Version (cont.)
SAPS II 0 points Abnormal value points
Chronic Disease Metastatic cancer 9 points
Hematological malignancy 10 points
AIDS 17 points
SAPS II SCORE: add
worst value for last
24 hours
Type of Admission Scheduled
surgical
Medical 6 points
Unscheduled surgical 8 points
*Mechanical ventilation includes the use of continuous positive airway pressure (CPAP).
SAPS II expanded
Value Points
Age, years ,40 0
40–59 0.1639
60–69 0.2739
70–79 0.369
.79 0.6645
Sex Male 0.2083
Female 0
Length of Hospital Stay Before ICU Admission ,24 hours 0
1 day 0.0986
2 days 0.1944
3–9 days 0.5284
.9 days 0.9323
Patient’s Location Before ICU Emergency room or mobile
emergency unit
0
Ward in same hospital 0.2606
Other hospital 0.3381
Clinical Category Medical patient 0.6555
Other 0
Intoxication No 1.6693
Yes 0
SAPS II (Expanded) = 0.0742 3 SAPS II score + the sum of the expanded variables
To calculate the predicted mortality:
Logit = 214.4761 + 0.0844 3 SAPS II(expanded) + 6.6158 3 log[SAPS II(expanded) + 1]
then
predicted mortality = e
(Logit)
/[1 + e
(Logit)
]
Adapted from Le Gall, J. R. et al. JAMA 270 (1993), 2957–2963; and Le Gall, J. R. et al. Critical Care (2005),
R645–R652.
84096_CH01_Chatburn.indd 13 6/16/10 6:31:45 AM
14  CHAPTER 1 Scores and Definitions
PediatriC risK of mortality (Prism) ■
(See Table 1–10.) Score designed to calculate the mortality risk in the pedi
atric intensive care unit. Developed from the original Physiologic Stability
Table 1–10 Pediatric Risk of Mortality (PRISM)
Infants
(,1 year old)
Children All ages Score
Systolic Blood
Pressure, mmHg
55–65 or
130–160
65–75 or
150–200
2
40–54 or .160 50–64 or .200 6
,40 ,50 7
Diastolic Blood
Pressure, mmHg
.110 6
Heart Rate,
beats per minute
,90 or .160 ,80 or .150 4
Respiratory Rate,
breaths per minute
61–90 51–70 1
apnea or .90 apnea or .70 5
Pao
2
/Fio
2
200–300 2
,200 3
Paco
2
torr
51–65 1
.65 5
Glasgow Coma
Score
,8 6
Pupillary Reaction unequal or
dilated
4
fixed and dilated 10
PT/PTT 1.5 3 control 2
Total Bilirubin,
mg/dl
.3.5 (.1 month
old)
6
Potassium, mEq/L 3–3.5 or 6.5–7.5 1
,3.0 or .7.5 5
Calcium, mg/dL 7–8 or 12–15 2
,7 or .15 6
Glucose, mg/dL 40–60 or
250–400
4
,40 or .400 8
Bicarbonate,
mEq/L
,16 or .32 3
Adapted from Pollack, M. M. et al. Crit Care Med 16 (1988), 1110–1116.
84096_CH01_Chatburn.indd 14 6/16/10 6:31:45 AM
Pediatric Index of Mortality II (PIM II)  15
Index. Values are measured during the first 24 hours after intensive care
admission.
First, calculate the risk of death (r).
r = (0.207 3 PRISM) 2 [0.005 3 (age in months)] 2 0.433 3 1
(if postoperative ) 2 4.782
Then
predicted death rate = e
r
/(1 + e
r
)
PediatriC index of mortality ii (Pim ii) ■
(See Table 1–11.) Score used to estimate mortality risk from data obtained
for each variable measured within the period from the time of first contact
(anywhere by an ICU doctor) to 1 hour after arrival to the intensive care unit.
Table 1–11 Pediatric Index of Mortality II (PIM II)
Variable Value
a Systolic blood pressure, mmHg MV
if unknown = 120
cardiac arrest = 0
shock with unmea
surable SBP = 30
b Pupillary reactions to bright light .3 mm and both
fixed = 1
other or unknown
= 0
c (Fio
2
3 100)/Pao
2
, mmHg MV
if unknown = 0
d Base excess in arterial or capillary blood,
mmol/L
MV
if unknown = 0
e Mechanical ventilation at any time during the
first hour in ICU
no = 0, yes = 1
f Elective admission to ICU no = 0, yes = 1
g Recovery from surgery or a procedure is the
main reason for ICU admission
no = 0, yes = 1
h Admitted following cardiac bypass no = 0, yes = 1
(continued)
84096_CH01_Chatburn.indd 15 6/16/10 6:31:45 AM
16  CHAPTER 1 Scores and Definitions
PIM2 = {0.01395 3 [absolute (a 2 120)]} + (3.0791 3 b) + (0.2888 3 c)
+ (0.104 3 absolute d) + (1.3352 3 e) – (0.9282 3 f) 2 (1.0244 3 g) +
(0.7507 3 h) + (1.6829 3 i) 2 (1.5770 3 j) 2 4.8841
Then
probability of death = e
PIM2
/(1 + e
PIM2
)
aPGar sCore ■
(See Table 1–12.) Score that is assessed at 1 and 5 minutes after delivery. It
may be repeated at 5minute intervals for infants with 5minute scores ,7.
Add points for each category.
Table 1–11 Pediatric Index of Mortality II (PIM II) (continued)
Variable Value
i Highrisk diagnosis is the main reason for ICU
admission
no = 0, yes = 1
Cardiac arrest preceding ICU admission
Severe combined immune deficiency
Leukemia or lymphoma after first induction
Spontaneous cerebral hemorrhage
Cardiomyopathy or myocarditis
Hypoplastic left heart syndrome
HIV infection
Liver failure is the main reason for ICU admission
Neurodegenerative disorder
j Lowrisk diagnosis is the main reason for ICU
admission
no = 0, yes = 1
Asthma
Bronchiolitis
Croup
Obstructive sleep apnea
Diabetic ketoacidosis
MV = Measured value. Enter the value for each variable in the equation.
Adapted from Slater et al. Int Care Med 29 (2003), 278–285.
84096_CH01_Chatburn.indd 16 6/16/10 6:31:45 AM
Silverman Score  17
Interpretation:
10: Best possible condition.
7–9: Adequate, no treatment.
4–6: Infant requires close observation and intervention such as suctioning.
,4: Infant requires immediate intervention such as intubation and further
examination.
silverman sCore ■
(See Figure 1–1.)
Table 1–12 Apgar Score
Sign 0 1 2
Heart Rate Absent ,100 bpm .100 bpm
Respiratory Effort Absent Irregular, shallow Good, crying
Muscle Tone Limp Some flexion of
extremities
Active motion
Reflex Irritability No response Grimace Cry
Color Blue, pale Body pink, extremities
blue
Completely pink
Data from Apgar, V. Anesth Analg 32 (1953), 260.
Upper
Chest
Lower
Chest
Xiphoid
Retraction
Chin
Movement
Expiratory
Grunt
G
r
a
d
e
0
G
r
a
d
e
1
G
r
a
d
e
2
None None
Synchronized
Lag on Insp.
SeeSaw Marked
Lips Part Naked Ear
Stethos. Only
Marked
Just Visible Just Visible
No Retraction
No Movement
of Chin
Chin Descends
Lips Closed
U
H

H

H
Figure 11 Silverman score. (Adapted from Silverman, W. A. and Andersen, D. H.
Pediatrics 17 (1956), 1–10.).
84096_CH01_Chatburn.indd 17 6/16/10 6:31:45 AM
18  CHAPTER 1 Scores and Definitions
Evaluates: Retractions, nasal flaring, and grunting.
Use: Evaluates respiratory distress in newborns.
Interpretation: Zero indicates no respiratory distress; 10 indicates severe
respiratory distress; 7 or greater indicates impending respiratory failure.
newborn resPiratory distress sCorinG ■
(rds) system
(See Table 1–13.) The sum of all the individual scores. Clinical RDS = score
$4 (overall mortality 25%); score $8 = severe respiratory distress with
impending failure (65% mortality).
Table 1–13 Newborn Respiratory Distress Scoring (RDS) System
*
RDS Score 0 1 2
Cyanosis None Inroom air In 40% Fio
2
Retractions None Mild Severe
Grunting None Audible with stetho
scope
Audible without
stethoscope
Air Entry (crying)
*
Clear Delayed or decreased Barely audible
Respiratory Rate (min) 60 60–80 .80 or apneic
episodes
*
Air entry represents the quality of the inspiratory breath sounds as heard in the midaxillary line.
Adapted from Downes, J. J. et al. Clin Pediatr (Phila) 9(6) (1970), 325–331.
sePsis definition ■
In an effort to standardize patients into categories of sepsis, a classification
has been widely adopted. Although it has limitations, when revised 10 years
later the same definitions stand with some new expansions. (From Bone,
R. C. et al. CHEST 101 (1992), 1644–1655 and Levy, M. M. et al. Critical
Car Med 31 (2003), 1250–1256.)
Systemic Inflammatory Response Syndrome
More than one of the following:
1. Body temperature greater than 388C
2. Heart rate greater than 90 beats per minute
84096_CH01_Chatburn.indd 18 6/16/10 6:31:45 AM
Sepsis Definition  19
3. Tachypnea (respiratory rate .20 breaths per minute) or hyperventilation
(Paco
2
,32 mmHg at sea level)
4. White blood cell count $12000 or #4000/cu mm.
Infection
Pathologic process caused by the invasion of normally sterile tissue or fluid
or body cavity by pathogenic or potentially pathogenic microorganism.
Sepsis
Clinical syndrome defined by the presence of both infection (suspected or
confirmed) and systemic inflammatory response. Diagnostic criteria for sep
sis in the pediatric population are signs and symptoms of inflammation plus
infection with hyper or hypothermia (rectal temperature .38.5 or ,358C),
tachycardia and one of the following indications of organ dysfunction:
altered mental status, hypoxemia, increased serum lactate level, or bounding
pulses.
Severe Sepsis
Sepsis complicated by organ dysfunction. May use the SOFA score or the
MOD score (see above) to define organ dysfunction.
Septic Shock
Acute circulatory failure characterized by persistent arterial hypotension
unexplained by other causes. Septic shock in pediatric patients is defined as
tachycardia with signs of decreased organ perfusion (decreased peripheral
pulses compared with central pulses, altered mental status, capillary refill
.2 s, mottled or cool extremities, or decreased urine output).
Hypotension
Systolic blood pressure below 90 mmHg (in children ,2 SD below normal
for their age), a mean arterial pressure ,60 mmHg, or a reduction in systolic
blood pressure of .40 mmHg from baseline despite adequate volume resus
citation.
84096_CH01_Chatburn.indd 19 6/16/10 6:31:45 AM
20  CHAPTER 1 Scores and Definitions
2001 exPanded diaGnostiC Criteria for ■
sePsis
Infection (defined as a pathologic process induced by a microorganism),
documented or suspected, and some of the following:
General Variables
Fever (core temperature .38.38C)
Hypothermia (core temperature ,368C)
Heart rate .90 min or .2 SD above the normal value for age
Tachypnea
Altered mental status
Significant edema or positive fluid balance (.20 mL/kg over 24 h)
Hyperglycemia (plasma glucose .120 mg/dL) in the absence of diabetes
Inflammatory Variables
Leukocytosis (white blood cell count .12,000 mL)
Leukopenia (white blood cell count ,4000 mL)
Normal white blood cell count with .10% immature forms
Plasma Creactive protein .2 SD above the normal value
Plasma procalcitonin .2 SD above the normal value
Hemodynamic Variables
Arterial hypotension (systolic blood pressure ,90 mm Hg, mean arterial
pressure ,70, or a systolic blood pressure decrease .40 mm Hg in
adults or ,2 SD below normal for age)
Mixed venous oxygen saturation .70%
Cardiac index .3.5 Lmin ? m
2
Organ Dysfunction Variables
Arterial hypoxemia (Pao
2
/Fio
2
,300)
Acute oliguria (urine output ,0.5 mL/kg/h or 45 mmol/L for at least 2 h)
Creatinine increase .0.5 mg/dL
Coagulation abnormalities (INR .1.5 or aPTT .60 s)
Ileus (absent bowel sounds)
84096_CH01_Chatburn.indd 20 6/16/10 6:31:46 AM
Lung Injury Score (Murray Score)  21
Thrombocytopenia (platelet count ,100,000 mL)
Hyperbilirubinemia (plasma total bilirubin .4 mg/dL)
Tissue Perfusion Variables
Hyperlactatemia (.1 mmol/L)
Decreased capillary refill or mottling
vasoPressor sCore (inotroPiC sCore, ■
CatheCholamine index)
Score used to describe the dose of vasopressors used.
inotropic score = (dopamine dose 3 1) + (dobutamine dose 3 1) +
(adrenaline dose 3 100) + (noradrenaline dose 3 100) +
(phenylephrine dose 3 100)
vasopressor dependency index = inotropic score/MAP
Data from Cruz, D. N. et al. JAMA 301(23) (2009), 2445–2452.
aCute resPiratory distress syndrome ■
definition
As defined by Bernard, et al. (Am J Respir Crit Care Med 149 (1994), 818–
824), all of the following criteria must be present
Acute onset ■
Pa ■ o
2
/Fio
2
#200 mmHg (ARDS)
Pa ■ o
2
/Fio
2
#300 mmHg (acute lung injury, ALI)
Bilateral infiltrates on chest radiograph consistent with pulmonary ■
edema
Pulmonary artery occlusion pressure ■ #18 mmHg or no clinical evidence
of left atrial hypertension
lunG injury sCore (murray sCore) ■
(See Table 1–14.) Designed to characterize the presence and extent of a pul
monary damage, the lung injury score was part of a threecomponent defini
tion in the original paper. The lung injury score was used as the definition for
ARDS (Score .2.5), but it is still used rather to characterize the severity of
lung disease in clinical trials.
84096_CH01_Chatburn.indd 21 6/16/10 6:31:46 AM
22  CHAPTER 1 Scores and Definitions
Table 1–14 Lung Injury Score (Murray Score)
SCORE
0 1 2 3 4
Chest Radiograph
Number of Quadrants with
Alveolar Consolidation
None 1 2 3 4
Hypoxemia
Pao
2
/Fio
2
$300 225–299 175–224 100–174 ,100
PEEP
cmH
2
0
#5 6–8 9–11 12–14 $15
Lung Compliance
mL/cm H
2
0
$80 60–79 40–59 20–39 #19
Add individual scores for each category and then divide by the number of components used. (i.e., not all
patients have all measurements).
Adapted from Murray, et al. Am Rev Respir Dis 138 (1988), 720–723.
ventilatorfree days ■
The number of ventilatorfree days is used to evaluate the effects of therapies
in critical care. This number combines the effects of mortality and the dura
tion of mechanical ventilation in patients who survive. It assumes that any
therapy that decreases duration of mechanical ventilation in patients who
survive also increases the number of patients that survive. The number is
calculated as
ventilatorfree days = number of days from day 1 to day 28
on which a patient breathed without assistance (if the period
of unassisted breathing lasted at least 48 consecutive hours).
If patient dies or requires more than 28 days of mechanical ventilation, the
value is 0. (From Schoenfeld, D. A. et al. Crit Care Med 30 (2002), 1772–
1777.)
Pneumonia definitions ■
The following definitions are from the American Thoracic Society and
Infectious Diseases Society of America in 2005 (Am J Respir Crit Care Med
171 (2005), 388–416).
84096_CH01_Chatburn.indd 22 6/16/10 6:31:46 AM
Pneumonia Definitions  23
CommunityAcquired Pneumonia
Pneumonia occurring within 48 hours of admission in patients with no crite
ria for healthcareassociated pneumonia.
VentilatorAssociated Pneumonia
Pneumonia occurring ■ .48 hours after endotracheal intubation.
Defined as a new lung infiltrate on chest radiography plus at least two ■
of the following: fever, 388C, leukocytosis or leukopenia, and purulent
secretions.
HospitalAcquired Pneumonia
Pneumonia occurring $48 hours after hospital admission
Risk factors for multidrug resistant bacteria:
Antibiotic therapy within 90 days of infection. ■
Current hospitalization of ■ $5 days.
High frequency of antibiotic resistance in community or specific hospi ■
tal unit.
Immunosuppressive disease or therapy. ■
Presence of healthcareassociated pneumonia risk factors for multidrug ■
resistant bacteria.
HealthcareAssociated Pneumonia
Pneumonia occurring #48 hours of admission in patients with any risk factor
for multidrug resistant bacteria as cause of infection:
Hospitalization for ■ $2 days in an acutecare facility within 90 days of
infection.
Nursing home or longterm acutecare facility resident. ■
Antibiotic therapy, chemotherapy, or wound care in last 30 days. ■
Hemodialysis at a hospital or clinic. ■
Home infusion therapy or wound care. ■
Family member with infection due to a multidrug resistant bacteria. ■
84096_CH01_Chatburn.indd 23 6/16/10 6:31:46 AM
24  CHAPTER 1 Scores and Definitions
CliniCal Pulmonary infeCtion sCore ■
(See Table 1–15.) Originally described by Pugin et al. (Am Rev Resp Dis 143
(1991), 1121–1129) and later modified by Singh et al. (AJRCCM 162 (2000),
505–511). A score developed to establish a numerical value of clinical,
radiographic, and laboratory markers for pneumonia. Scores above 6 sug
gest pneumonia (specificity and sensitivity have been consistently less than
in initial validation study). Singh et al. showed that some patients with a low
clinical suspicion of ventilatorassociated pneumonia (CPIS #6) can have
antibiotics safely discontinued after 3 days, if the subsequent course suggests
that the probability of pneumonia is still low. (See also Table 1–16.)
Table 1–15 Clinical Pulmonary Infection Score
Score 0 1 2
Temperature $36.5 and #38.4 $38.5 and #38.9 $39 or #36.4
Blood Leukocytes
10
3
mm
3
$4 and #11 ,4 or .12
Tracheal
Secretions
None Nonpurulent Purulent
Oxygenation
Pao
2
/Fio
2
, mmHg
.240 or ARDS
*
#240 and no
ARDS
Chest Radiography No opacity Diffuse (patchy)
opacities
Localized opacity
Progression of
Radiographic
Opacities
No progression progression (after
HF
**
and ARDS
excluded)
Culture of
Tracheal Aspirate
Pathogenic bac
teria cultured in
rare/few quanti
ties or no growth
Pathogenic bac
teria cultured in
moderate or heavy
quantity
Add a point (+1) if: Bands are .50% or same pathogenic bacteria seen on Gram
stain.
*
ARDS (Acute Respiratory Distress Syndrome) defined as Pao
2
/Fio
2
200, PAOP ,18 mmHg and acute bilateral
infiltrates.
**
HF: heart failure.
Adapted from Singh et al. AJRCCM 162 (2000), 505–511.
84096_CH01_Chatburn.indd 24 6/16/10 6:31:46 AM
Definitions for Weaning and Liberation of Mechanical Ventilation  25
Table 1–16 Clinical Criteria for the Diagnosis of Pneumonia as Defined by the
National Nosocomial Infection Surveillance System
Radiographic
Two or more serial chest radiographs with new or progressive and persistent infil
trate or cavitation or consolidation (one radiograph is sufficient in patients without
underlying cardiopulmonary disease)
Clinical
One of the following:
Fever .388C (100.48F) with no other recognized cause
WBC count ,4,000/mL or .12,000 mL
For adults .70 yr old, altered mental status with no other recognized cause
And at least two of the following:
Newonset purulent sputum or change in character of sputum, or increase in respi
ratory secretions or suctioning requirements
Newonset or worsening cough, dyspnea, or tachypnea
Rales or bronchial breath sounds
Worsening gas exchange, increased oxygen requirements, increased ventilatory
support
Microbiology (optional)
Positive culture result (one): blood (unrelated to other source), pleural fluid, quanti
tative culture by BAL or PSB, .5% BALobtained cells contain intracellular bacteria
BAL: Bronchoalveolar lavage, PSB: Protected specimen brush
From CDC. NNIS Criteria for Determining Nosocomial Pneumonia. Atlanta, GA: U.S. Department of Health and
Human Services, CDC, 2003. Prozencaski. CHEST, 2006; 130:597–604.
definitions for weaninG and liberation of ■
meChaniCal ventilation
Multiple terms and definitions are used indistinctly to describe the process
of discontinuation of mechanical ventilation. The process of freeing a patient
from ventilator assistance is often termed weaning (which for some includes
the process of extubation). We favor the term liberation or discontinuation
to describe the cessation of ventilator support. Table 1–18 shows the latest
multi society attempt to define weaning/liberation of mechanical ventilation.
84096_CH01_Chatburn.indd 25 6/16/10 6:31:46 AM
26  CHAPTER 1 Scores and Definitions
Table 1–17 Definitions for Weaning and Liberation of Mechanical Ventilation
Weaning success: is the extubation and the absence of ventilatory support for the
following 48 h
Weaning failure: is one of the following: (1) failed spontaneous breathing trial; or
(2) reintubation and/or resumption of ventilator support following successful
extubation; or (3) death within 48 h following extubation
Simple weaning: Patients who proceed from initiation of weaning to successful
extubation on the first attempt
Difficult weaning: Patients who fail initial weaning and require up to three spon
taneous breathing trials, or as long as 7 days from the first attempt to achieve
successful weaning
Prolonged weaning: Patients who fail at least three weaning attempts or require
more than 7 days of weaning after the first spontaneous breathing trial
Failed spontaneous breathing trial:
Subjective criteria: Agitation, anxiety, depressed mental status, diaphoresis, cyano
sis, increased accessory muscle activity, facial signs of distress and dyspnea
Objective criteria: Pao
2
#50–60 mmHg on Fio
2
$0.5 or Sao
2
,90%; Paco
2
.50
mmHg or an increase in Paco
2
.8 mmHg; pH ,7.32 or a decrease in pH $0.07 pH
units; shallow breathing index (respiratory rate/tidal volume) .105 breaths/min/L;
respiratory rate .35 breaths/min or increased by .50%; heart rate .140 beats/
min or increased by $20%; systolic blood pressure .180 mmHg or increased by
$20% or ,90 mmHg; or cardiac arrhythmias
Data from Boles, J. M. et al. Eur Respir J 29 (2007), 1033–1056.
intubation diffiCulty sCale ■
(See Table 1–18.) Quantitative score used to evaluate intubation difficulty,
conditions, and techniques.
wells sCore: Pulmonary embolism ■
The original interpretation of results of the Wells score for pulmonary embo
lism was modified for the Christopher study. Both are presented here.
Original Score
Symptoms of deep venous thrombosis (DVT): Leg swelling, pain with ■
palpation (3 points).
No alternative diagnosis better explains the illness (3 points). ■
84096_CH01_Chatburn.indd 26 6/16/10 6:31:46 AM
Wells Score: Pulmonary Embolism  27
T
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84096_CH01_Chatburn.indd 27 6/16/10 6:31:46 AM
28  CHAPTER 1 Scores and Definitions
Tachycardia with pulse ■ .100 (1.5 points).
Immobilization ( ■ $3 days) or surgery in the previous four weeks (1.5
points).
Prior history of DVT or pulmonary embolism (1.5 points). ■
Presence of hemoptysis (1 point). ■
Presence of malignancy (1 point). ■
Results: 7–12 points: High probability
2–6 points: Moderate probability
0–1 points: Low Probability
Modified Score
Use original criteria.
Results: More than 4 points: Pulmonary embolism likely
Less than 4 points: Pulmonary embolism unlikely
Data from Wells, P. S. et al. Thrombosis and Haemostasis 83 (2000), 416–
420; and van Belle, A. et al. JAMA 295 (2006), 172.
wells sCore: deeP venous thrombosis (dvt) ■
The original Wells score and its interpretation were modified in a later arti
cle. Both are presented here.
Original Score
Paralysis, paresis, or recent orthopedic casting of lower extremity (1 ■
point).
Recently bedridden ( ■ $3 days) or major surgery within past 4 weeks (1
point).
Localized tenderness in deep vein system (1 point). ■
Swelling of entire leg (1 point). ■
Calf swelling 3 cm greater than other leg (measured 10 cm below the ■
tibial tuberosity) (1 point).
Pitting edema greater in the symptomatic leg (1 point). ■
Collateral nonvaricose superficial veins (1 point). ■
84096_CH01_Chatburn.indd 28 6/16/10 6:31:46 AM
Wells Score: Deep Venous Thrombosis (DVT)  29
Active cancer or cancer treated within 6 months (1 point). ■
Alternative diagnosis more likely than DVT ( ■ 22 points).
Results: 3–8 points: High probability of DVT
1–2 points: Moderate probability
22–0 points : Low Probability
Modified Score
Add this criteria to the original.
Previous documented DVT (1 point). ■
Results: 2 or . points: DVT likely
1 or less points: DVT unlikely
Data from Wells, P. S. et al. Lancet 350 (1997), 1795–1798; and Wells, P.
S., Anderson, D. R., Rodger, M., et al. N Engl J Med 349 (2003), 179–1227.
84096_CH01_Chatburn.indd 29 6/16/10 6:31:46 AM
Intentional Blank 30
84096_CH01_Chatburn.indd 30 6/16/10 6:31:46 AM
CHAPTER
2
CHAPTER
2
Pulmonary
Function
Kevin McCarthy, RPFT
84096_CH02_Chatburn.indd 31 6/16/10 6:32:29 AM
32  CHAPTER 2 Pulmonary Function
The following prediction equations are compiled from the works of many
scientific investigators. Recent work has shown that Caucasians have signifi
cantly higher values for lung function than nearly every other ethnic group
studied. Typical normal values for spirometry volumes in nonCaucasian
individuals range from 85%–88% of the Caucasian predicted value. The
NHANES III (Hankinson et al.) predicted set for spirometry provides spe
cific regression equations for Caucasians, AfricanAmericans, and Mexican
Americans; Caucasian values are presented here. Readers are directed to the
reference to see these specific reference equations.
Tidal Volume (Vt)
The volume of gas inspired or expired during one respiration cycle.
Prediction equations are shown in Table 2–1.
Table 2–1 Tidal Volume (Vt)
Infant Vt = 7.1 mL/kg
Child Vt = 7.5 mL/kg
Male adult Vt = 7.8 mL/kg
Female adult Vt = 6.6 mL/kg
Respiratory Rate or Frequency (f)
The number of respiratory cycles per unit of time, usually 1 minute.
Prediction equations for respiratory frequency are shown in Table 2–2.
Table 2–2 Respiratory Rate or Frequency (f)
Age (6–25 yr) f (bpm) = 30.9 2 0.80 age (years)
Age (25–80 yr) f (bpm) = 7.07 + 0.16 age (years)
Alveolar Ventilation (Va)
The effective rate at which air enters the region of the lungs that participates
in gas exchange. The calculation of alveolar ventilation is
V
#
a =
f 3 (Vt 2 Vd)
where Vd = physiologic dead space volume.
Typical values for the preceding and more are shown in Table 2–3.
.
84096_CH02_Chatburn.indd 32 6/16/10 6:32:29 AM
Spirometry  33
Table 2–3 Typical Values for Tidal Volume (Vt), Frequency (f), Minute Volume (V
#
e),
Dead Space (Vd), and Alveolar Ventilation (V
#
a)
Age (yr)
Newborn 1 5 12 15 Adult
Vt (mL) 20 78 130 260 360 500
f (bpm) 36 24 20 16 14 12
V
#
e (mL/min)
720 1872 2600 4160 5040 6000
Vd (mL) 7.5 21 49 105 141 150
V
#
a (mL/min)
450 1368 1620 2480 3066 4200
Spirometry ■
Spirometry typically consists of a maximum inspiration to complete maximal
voluntary lung expansion followed by maximal forced expiration, sustained
until flow falls below 25 mL/s for at least one second or for as long as the
patient can safely continue up to a timed endpoint, generally considered to be
15 s. In this setting, the total volume exhaled is called the forced vital capac
ity (FVC). When the patient exhales with less than maximal force for as long
as can be safely tolerated, this is called the slow vital capacity (SVC). When
the patient exhales as completely or for as long as possible, then inhales
maximally, this is called the inspiratory vital capacity (IVC). The latter two
methods are generally used for lung volume determinations and diffusing
capacity tests, respectively. In individuals with normal lung function, the
difference between any of these volumes is minimal, and the prediction equa
tions for FVC can be used for SVC or IVC.
Vital Capacity (VC)
Volume change of the lungs measured on a complete expiration after a
maximum inspiration or a complete inspiration after a maximum expiration.
Prediction equations are shown in Table 2–4. Typical values are shown in
Table 2–5.
84096_CH02_Chatburn.indd 33 6/16/10 6:32:29 AM
34  CHAPTER 2 Pulmonary Function
Table 2–4 Prediction Equations for Vital Capacity
Infant (crying VC), (mL) 3.36 length (cm) 2 104
Child , 8 yr, (mL) 1.63 height (cm)
2.87
3 10
23
Male child (8–19 yr), (L) 20.2584 2 0.20415 age + 0.010133 age
2
+ 0.00018624
height (cm)
2
Female child (8–17 yr), (L) 20.8710 + 0.06537 age + 0.00011496 height (cm)
2
Male adult ($20 yr), (L) 48.1 height (cm) 2 20.0 age 2 2810
Female adult ($18 yr), (L) 40.4 height (cm) 2 22.0 age 2 2350
Table 2–5 Typical Values for Vital Capacity
Age (yr)
Newborn
(mL)
1
(mL)
5
(L)
12
(L)
15
(L)
Adult
male, (L)
Adult
female, (L)
VC 100
*
500 1.25 2.75 4.30 5.00 3.50
*
Crying vital capacity (CVC).
Functional Residual Capacity (FRC)
The volume of gas remaining in the lungs at the end of relaxed (passive)
expiration. Prediction equations are shown in Table 2–6. Typical values are
shown in Table 2–7.
Table 2–6 Prediction Equations for Functional Residual Capacity
Infant (1–5 days) FRC (mL) = 30 mL/kg
Small child (1 mo–5 yr) FRC (mL) = 0.0157 length (cm)
2.238
Child (5–16 yr) FRC (L) = [0.00088 height (cm)
2.91
] 3 10
23
Male adult FRC (L) = 0.472 height (cm) + 0.009 age 2 5.29
Female adult FRC (L) = 0.036 height (cm) + 0.0031 age 2 3.182
Table 2–7 Typical Values for Functional Residual Capacity
Age (yr)
5 12 15 Adult (M) Adult (F)
FRC (L) 0.7 1.90 2.80 3.00 2.75
84096_CH02_Chatburn.indd 34 6/16/10 6:32:29 AM
Spirometry  35
Residual Volume (RV)
That volume of gas remaining in the lungs after maximum expiration.
Prediction equations are shown in Table 2–8. Typical values are shown in
Table 2–9.
Table 28 Prediction Equations for Residual Volume
Child (5–16 yr) RV (L) = [0.032 height (cm)
2.04
] 3 10
23
Male adult RV (L) = 0.0216 height (cm) + 0.0207 age 2 2.84
Female adult RV (L) = 0.0197 height (cm) + 0.0201 age 2 2.421
Table 2–9 Typical Values for Residual Volume
Age (yr)
5 12 15 Adult (M) Adult (F)
RV (L) 0.40 0.90 1.10 1.50 1.20
Total Lung Capacity (TLC)
The volume of gas in the lung after maximum inspiration. Prediction equa
tions are shown in Table 2–10. Typical values are shown in Table 2–11.
Table 2–10 Prediction Equations for Total Lung Capacity
Child (5–16 yr) TLC (L) = [0.003 height (cm)
2.80
] 3 10
23
Male adult TLC (L) = 0.0795 height (cm) + 0.0032 age 27.333
Female adult TLC (L) = 0.059 height (cm) 2 4.537
Table 2–11 Typical Values for Total Lung Capacity
Age (yr)
5 12 15 Adult (M) Adult (F)
TLC (L) 1.60 3.70 5.25 6.25 5.00
Residual Volume to Total Lung Capacity Ratio (RV/TLC)
The fraction of total lung capacity (TLC) that is taken up by residual volume
(RV), expressed as a percent.
RV/TLC = 25% ± 5% in healthy individuals
84096_CH02_Chatburn.indd 35 6/16/10 6:32:29 AM
36  CHAPTER 2 Pulmonary Function
Forced Vital Capacity (FVC)
A vital capacity performed with a maximum expiratory effort sustained until
empty or a exhalation time of 15 s. Prediction equations are shown in Table
2–12.
Table 2–12 Prediction Equations for Forced Vital Capacity
Male child (8–19 yr), (L) 20.2584 2 0.20415 age + 0.010133 age
2
+ 0.00018642
height (cm)
2
Female child (8–17 yr), (L) 21.2082 + 0.05916 age + 0.00014815 height (cm)
2
Male adult ($20 yr), (L) 20.1933 + 0.00064 age 2 0.000269 age
2
+ 0.00018642
height (cm)
2
Female adult ($18 yr), (L) 20.3560 + 0.01870 age + 0.000382 age
2
+ 0.00014815
height (cm)
2
Forced Expiratory Volume in 1 Second (FEV
1
)
The volume of gas exhaled in 1 second during the execution of a forced vital
capacity. Prediction equations are shown in Table 2–13.
Table 2–13 Prediction Equations for Forced Expiratory Volume in 1 Second
Male child (8–19 yr), (L) 20.7453 2 0.04106 age + 0.004477 age
2
+ 0.00014098
height (cm)
2
Female child (8–17 yr), (L) 20.8710 + 0.06537 age + 0.00011496 height (cm)
2
Male adult ($20 yr), (L) 0.5536 2 0.01303 age 2 0.000172 age
2
+ 0.00014098
height (cm)
2
Female adult ($18 yr), (L) 0.4333 2 0.00361 age 2 0.000194 age
2
+ 0.00011496
height (cm)
2
Forced Expiratory Volume–Forced Vital Capacity Ratio
(FEV/FVC)
Forced expiratory volume (timed) to forced vital capacity ratio, expressed as
a percentage. Prediction equations are shown in Table 2–14. Typical values
for a healthy person, 25 years old are shown below:
FEV
0.5
sec = 60% of FVC
FEV
1
sec = 83% of FVC
FEV
2
sec = 94% of FVC
FEV
3
sec = 97% of FVC
84096_CH02_Chatburn.indd 36 6/16/10 6:32:29 AM
Spirometry  37
Table 2–14 Prediction Equations for Mean Normal FEV
1
/FVC Ratio (%)
Male, (%) 88.066 2 0.2066 age
Female, (%) 90.809 2 0.2125 age
Note: The FEV
1
/FVC ratio is age dependent and declines with aging in
adults. The predicted lower limit of normal is approximately 9%–10% below
the mean predicted value.
Forced Expiratory Flow 25%–75% (FEF
25%–75%
)
Mean forced expiratory flow during the middle half of the forced vital capac
ity. The 95% confidence interval for the FEF
25%–75%
has recently been shown
to increase with age, making the practice of approximating the lower limit
of normal for this parameter at 80% of the mean predicted value invalid.
Prediction equations are shown in Table 2–15.
Table 2–15 Prediction Equations for Forced Expiratory Flow 25%–75%
Male child (8–19 yr), (L) 21.0863 + 0.13939 age + 0.00010345 height (cm)
2
Female child (8–17 yr), (L) 22.5284 + 0.52490 age 2 0.015309 age
2
+ 0.00006982
height (cm)
2
Male adult ($20 yr), (L) 2.7006 2 0.04995 age + 0.00010345 cm
2
Female adult ($18 yr), (L) 2.3670 2 0.01904 age 2 0.0002 age
2
+ 0.00006982
height (cm)
2
Peak Expiratory Flow (PEF)
The maximum flow recorded at any point during a forced expiratory maneu
ver. Prediction equations are shown in Table 2–16.
Table 216 Prediction Equations for Peak Expiratory Flow
Male (8–19), (L/min) (20.5962 2 0.12357 age + 0.013135 age
2
2 0.00024962
height (cm)
2
) 3 60
Female (8–17), (L/min) (23.6181 + 0.60644 age 2 0.016846 age
2
2 0.00018623
height (cm)
2
) 3 60
Male ($20), (L/min) (1.0523 + 0.08272 age 2 0.001301 age
2
+ 0.00024962
height (cm)
2
) 3 60
Female ($18), (L/min) (0.9267 + 0.06929 age 2 0.001031 age
2
+ 0.00018623 height
(cm)
2
) 3 60
84096_CH02_Chatburn.indd 37 6/16/10 6:32:29 AM
38  CHAPTER 2 Pulmonary Function
Maximum Voluntary Ventilation (MVV)
The volume of air expired in 1 minute during repetitive maximum respiratory
efforts, usually measured for 15 s and multiplied by 4. The ideal respiratory
rate for measurement of MVV is typically 90 to 120 breaths/minute, but
multiple efforts will show the ideal rate for any given patient. Maximum val
ues for MVV in patients with airflow obstruction may be achieved at lower
respiratory rates, depending on disease severity. The FEV
1
3 40 will yield an
approximate MVV for patients with airflow obstruction and normal inspira
tory flows. Prediction equations are shown in Table 2–17.
Table 2–17 Prediction Equations for Maximum Voluntary Ventilation
Male child (L/min) 2.165 age + 1.076 height (cm) 2 89.66
Female child (L/min) 2.725 age + 0.772 height (cm) 2 57.84
Male adult (L/min) 1.193 height (cm) 2 0.816 age 2 37.9
Female adult (L/min) 0.8425 height (cm) 2 0.685 age 2 4.87
Airway Resistance (Raw)
An effective measure of the flow resistance of the airways obtained by
plethysmographic techniques, presumed to be measured at FRC. Prediction
equations are shown in Table 2–18.
Table 2–18 Prediction Equations for Airway Resistance
Infant (cm H
2
O/L/sec) mean value 19.2 ; 5.6
Child (cm H
2
O/L/sec) 3.87 3 10
6
3 height (cm)
22.67
Adult (cm H
2
O/L/sec) 0.5 2 2.0
Airway Conductance (Gaw)
The reciprocal of airway resistance (1/Raw). Airway resistance and conduc
tance both vary with thoracic gas volume (TGV). However, the relationship
between Gaw and TGV is more nearly linear than the relationship between
Raw and TGV. Prediction equations are shown in Table 2–19.
Table 2–19 Prediction Equations for Airway Conductance
Child (1–5 yr) Gaw (L/sec/cm H
2
O) = 0.143 3 TGV (L) 2 0.644
Child (6–18 yr) Gaw (L/sec/cm H
2
O) = 10
[2.6498 log height (cm) 2 6.2210]
Female adult Gaw (L/sec/cm H
2
O) = 0.29 TGV (L) 2 0.27
Male adult Gaw (L/sec/cm H
2
O) = 0.28 TGV (L) 2 0.73
84096_CH02_Chatburn.indd 38 6/16/10 6:32:29 AM
Spirometry  39
Lung Compliance (Cl)
An effective measure of the elastic behavior of the lungs defined as the
ratio of the change in lung volume to the change in transpulmonary pressure
when there is no flow. Transpulmonary pressure is typically calculated using
esophageal pressure as a surrogate for pleural pressure. Lung compliance
is typically measured during passive exhalation from TLC to FRC with the
segment from FRC to FRC + 0.5 L taken as a standardized portion of the
pressure–volume curve to report as representing lung compliance. Prediction
equations are shown in Table 2–20.
Table 2–20 Prediction Equations for Lung Compliance
Infant Cl (mL/cm H
2
O) = 2.0 weight (kg)
Child Cl (L/cm H
2
O) = 0.00102 310
[2.0817 3 log height (cm) 2 2.3699]
Adult Cl (L/cm H
2
O) = 0.05 FRC (L)
Carbon Monoxide Diffusing Capacity (DLco)
Amount of gas diffusing across the alveolar capillary membrane per unit
of pressure difference per minute. Prediction equations are shown in Table
2–21.
Table 2–21 Prediction Equations for Carbon Monoxide Diffusing Capacity
Child (mL/min/mm Hg) 2.986 3 10
[2.0867 log height (cm) 2 3.70145]
Male adult (mL/min/mm Hg) 0.164 height (cm) 2 0.229 age + 12.9
Female adult (mL/min/mm Hg) 0.16 height (cm) 2 0.111 age + 2.24
Maximum Inspiratory Pressure (Pimax)
The maximum inspiratory pressure that can be generated against an occlu
sion starting at or near residual volume. Prediction equations are shown in
Table 2–22.
Table 2–22 Prediction Equations for Maximum Inspiratory Pressure
Male (6–60 yr) Pimax (cm H
2
O) = 143 2 0.55 age
Female (6–60 yr) Pimax (cm H
2
O) = 104 2 0.51 age
Maximum Expiratory Pressure (Pemax)
The maximum expiratory pressure that can be generated against an occlu
sion starting at or near total lung capacity. Prediction equations are shown in
Table 2–23.
84096_CH02_Chatburn.indd 39 6/16/10 6:32:29 AM
40  CHAPTER 2 Pulmonary Function
Table 2–23 Prediction Equations for Maximum Expiratory Pressure
Male (6–60 yr) Pemax (cm H
2
O) = 268 2 1.03 age
Female (6–60 yr) Pemax (cm H
2
O) = 170 2 0.53 age
Tables 2–24, 2–25, and 2–26 show typical patterns of pulmonary function
test as well as values used to assess the severity of the defects.
Table 2–24 Summary of Pulmonary Function Profile in Obstructive
and Restrictive Diseases
*
Obstruction Restriction
VC S to T (when severe) T to T T
FEV
1
T to T T T to T T
FEV
1
/FVC T to T T S to c
TLC S to c T to T T
FRC c to c c c S to T
RV c to c c c S to T
RV/TLC c to c c c S to c
MVV T to T T S to T
FEF
25%275%
T to T T S to T
*
S = normal; c = increased; T = decreased. Typically, restriction means T VC and TLC;
normal flow rates; obstruction means T VC and flow rates; normal or increased TLC.
Table 2–25 Assessment of Severity for Obstructive and
Restrictive Pulmonary Diseases
*
FEV
1
, Percentage of Predicted
Mild .70
Moderate 60–69
Moderately severe 50–59
Severe 35–49
Very severe ,35
*
Note: The presence of a restrictive ventilatory disorder should be confirmed by
measurement of lung volumes. The sensitivity of a reduced FVC for restriction
(confirmed by a reduced TLC on lung volumes) is approximately 60%.
84096_CH02_Chatburn.indd 40 6/16/10 6:32:30 AM
Bronchial Inhalation Challenges  41
Table 2–26 General Risk of Developing Postoperative Pulmonary Complications in
Patients With Abnormal Pulmonary Function
Low Risk Moderate Risk High Risk
VC (%pred) .60 40–60 ,40
FEV
1
/FVC (%) .55 40–55 ,40
MVV (%pred) .60 40–60 ,40
PaCO
2
(mm Hg) ,45 45–50 .50
PaO
2
(mm Hg room air) .60 40–60 ,40
Bronchial inhalation challengeS ■
Pharmacologic agents are used to identify patients with suspected airway
hyperreactivity. Table 2–27 shows the dosing schedule approved by the FDA
for administering a methacholine challenge test. The minimum change in
baseline FEV
1
or sGaw for a positive study is shown in Table 2–28.
Table 2–27 FDAApproved Dosing Schedule for Methacholine Challenge
*
Methacholine Concentration (mg/mL) Number of Breaths
0.025 5
0.25 5
2.5 5
10.0 5
25.0 5
*
Five breaths at each dose, with a 0.6s nebulization burst at FRC and a 5 to 10s breathhold
for each breath.
Table 2–28 Significant Spirometry Changes Following Bronchial
Challenge
Test Minimum Change From Baseline (%)
FEV
1
220
sGaw (specific Gaw) 240
Methacholine Results: The provocative concentration of methacholine solu
tion that caused a 20% fall in FEV
1
from baseline (PC20fev
1
) is calculated
by interpolation when the last dose caused a greater than 20% fall. Table
2–29 shows a scheme for categorizing the PC20fev
1
.
84096_CH02_Chatburn.indd 41 6/16/10 6:32:30 AM
42  CHAPTER 2 Pulmonary Function
Table 2–29 Categorization of Bronchial Responsiveness
*
PC20fev
1
(mg/mL) Interpretation
.16.0 Normal bronchial responsiveness
4.0–16.0 Borderline bronchial hyperresponsiveness (BHR)
1.0–4.0 Mild BHR (positive test)
,1.0 Moderate to severe BHR
*
Caveats: assumes baseline airflow obstruction is absent, spirometry quality is good, and there is
a substantial postchallenge FEV
1
recovery.
exerciSe phySiology ■
Resting Energy Expenditure (REE)
The minimum level of energy required to sustain the body’s vital functions in
a resting state. Prediction equations are shown in Table 2–30. Average rates
of energy expenditure appear in Table 2–31.
Table 2–30 Prediction Equations for Resting Energy Expenditure
Male adult REE = 66.5 + 13.8 weight (kg) + 5.0 height (cm) 2 6.8 age
Female adult REE = 66.5 + 96 weight (kg) + 1.8 height (cm) 2 4.7 age
Table 2–31 Average Rates of Energy Expenditure for Men and
Women Living in the United States
Age Weight Height Energy Expenditure
Men 15–18 61 172 3000
19–22 67 172 3000
23–50 70 172 2700
.50 70 172 2400
Women 15–18 54 162 2100
19–22 58 162 2100
23–50 58 162 2000
.50 58 162 1800
Maximum Oxygen Consumption (Vo
2
max)
The highest oxygen consumption that an individual can obtain during physi
cal work; a measure of fitness. Technically, most cardiopulmonary stress
.
84096_CH02_Chatburn.indd 42 6/16/10 6:32:30 AM
Exercise Physiology  43
tests result in a measurement of V
#
o
2
peak. A true V
#
o
2
max is measured
when the oxygen uptake demonstrates a plateau in the face of an increasing
workload. Prediction equations and normal values are shown in Table 2–32.
Oxygen consumption varies with activity (Table 2–33) and underlying dis
ease (Table 2–34).
Table 2–32 Prediction Equations for
Maximum Oxygen Consumption (V
#
o
2
max)
Male adult 4.2 2 0.032 age
Female adult 2.6 2 0.016 age
Normal Values for V
#
o
2
max in Adults
Male child (#13 yr) (42 mL/min)/kg
Male child (.13 yr) (50 mL/min)/kg
Female child (=11 yr) (38 mL/min)/kg
Female child (.11 yr) (34 mL/min)/kg
Table 2–33 V
#
o
2
Requirements of Common Activities
Activity Vo
2
(mL/min)/kg
Desk work 4–7
Driving car 4–7
Level walking (1 mph) 4–7
Sweeping floors 7–11
Making beds 7–11
Automobile repair 7–11
Wheelbarrow (100lb load) 11–14
Bicycling (6 mph) 11–14
Golfing (pulling cart) 11–14
Tennis (doubles) 14–18
Painting masonry 14–18
Golf (carrying clubs) 14–18
Digging garden 18–21
Cycling (10 mph) 18–21
.
84096_CH02_Chatburn.indd 43 6/16/10 6:32:30 AM
44  CHAPTER 2 Pulmonary Function
T
a
b
l
e
2
–
3
4
P
a
t
t
e
r
n
s
o
f
R
e
s
p
o
n
s
e
t
o
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x
e
r
c
i
s
e
C
a
r
d
i
a
c
D
i
s
e
a
s
e
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b
s
t
r
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c
t
i
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t
e
r
s
t
i
t
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a
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i
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a
s
e
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e
c
o
n
d
i
t
i
o
n
e
d
V
#
o
2
m
a
x
T
T
T
T
T
T
V
#
e
/
M
V
V
2
c
c
2
H
R
m
a
x
(
%
p
r
e
d
)
.
9
5
%
V
a
r
i
a
b
l
e
;
l
o
w
w
h
e
n
s
e
v
e
r
e
8
0
%
.
9
5
%
O
2
p
u
l
s
e
(
m
a
x
)
T
T
T
T
T
V
d
/
V
t
2
c
c
2
A
T
T
T
(
l
i
k
e
l
y
t
o
b
e
a
b
s
e
n
t
w
h
e
n
s
e
v
e
r
e
)
T
2
P
a
o
2
2
T
T
T
2
2
=
W
i
t
h
i
n
n
o
r
m
a
l
r
a
n
g
e
;
T
=
m
i
l
d
c
h
a
n
g
e
;
T
T
=
m
a
r
k
e
d
c
h
a
n
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.
84096_CH02_Chatburn.indd 44 6/16/10 6:32:30 AM
Suggested Reading  45
Maximum Heart Rate (HRmax)
The highest heart rate attained during maximum exercise. Prediction equa
tions are shown in Table 2–35.
Table 2–35 Prediction Equations for Maximum Heart Rate
Child HRmax (bpm) = 195 ; 13
Adult HRmax (bpm) = 220 2 age
Heart Rate Reserve (HRR)
The difference between the predicted maximum heart rate and the actual
maximum exercise heart rate. The calculation of maximum heart rate reserve
is
HRR = predicted HRmax 2 observed HRmax.
Maximum Oxygen Pulse (MOP)
The quotient of predicted maximum oxygen consumption and predicted max
imum heart rate. The maximum oxygen pulse is generally a reflection of the
stroke volume. The prediction equation for maximum oxygen pulse is
MOP (mL/beat)
predicted V (mL/min)
predicted
O
=
2
max
HRmax (mL/min)
SuggeSted reading
American Thoracic Society/European Respiratory Society Task Force. Standardisation
of lung function testing: Interpretive strategies for lung function testing. Eur Respir
J 26 (2005), 948–968.
Hankinson, J. L., Odencrantz, J. R., and Fedan, K. B. Spirometric reference values
from a sample of the general U.S. population. Am J Respir Crit Care Med 159:1
(January 1999), 179–187
Cotes, J. E. Lung Function: Assessment and Application in Medicine. Oxford:
Blackwell Scientific Publications, 1993.
American Thoracic Society: Guidelines for Pulmonary Function Testing. Downloads
available from: http://www.thoracic.org/sections/publications/statements/index.html.
84096_CH02_Chatburn.indd 45 6/16/10 6:32:30 AM
46  CHAPTER 2 Pulmonary Function
Hughes, J. M. and Pride, N. B. Lung Function Tests: Physiological Principles and
Clinical Application, 5th ed. London: Balliere Tindall, 1999.
Wasserman, K., Hansen, J., Sue, D., Stringer, W., and Whipp, B. Principles of
Exercise Testing and Interpretation: Including Pathophysiology and Clinical
Applications, 4th ed. Philadelphia: Lippincott, Williams and Wilkins, 2004.
84096_CH02_Chatburn.indd 46 6/16/10 6:32:30 AM
CHAPTER
3
CHAPTER
3
Physiologic
Monitoring
84096_CH03_Chatburn.indd 47 6/16/10 6:37:40 AM
48  CHAPTER 3 Physiologic Monitoring
Gas ExchanGE ■
The equations in this section express the relationships that exist during gas
exchange in the steady state. They are based on the following two assump
tions:
1. that there is no carbon dioxide in the inspired gas, and
2. that the net exchange of nitrogen is negligible because of its very low
solubility.
All fractional gas concentrations are calculated on a dry gas basis.
Oxygen Uptake
The rate at which oxygen is removed from alveolar gas by the blood. Under
steadystate conditions, oxygen uptake equals oxygen consumption (the rate
at which oxygen is metabolized). See oxygen consumption on page 92.
Abbreviation: V
#
o
2
Units: mL/min (STPD)
Normal value: 240 mL/min (adults) or
100–180 mL/min/m
2
(children or adults)
6–8 mL/min/kg (infants)
Equation for Fio
2
,1.0:
V
#
O
2
5 V
#
E c FIO
2
a
1 2 FECO
2
2 FEO
2
1 2 FIO
2
b 2 FEO
2
d
Equation for Fio
2
= 1.0:
V
#
O
2
5 V
#
E 1FIO
2
2 FEO
2
2
where
V
#
e = exhaled minute volume (mL/min STPD)
Fio
2
= fraction of oxygen in inspired gas
FEO
2
= fraction of oxygen in mixed exhaled gas
FECO
2
= fraction of carbon dioxide in mixed exhaled gas
84096_CH03_Chatburn.indd 48 6/16/10 6:37:41 AM
Gas Exchange  49
Carbon Dioxide Output
Carbon dioxide output is a function of the amount of that gas produced by
metabolism and the level of alveolar ventilation. The equation relating these
variables may also be solved for alveolar ventilation.
Abbreviation: V
#
CO
2
Units: mL/min (STPD)
Normal value: 192 mL/min (adults) or
80–144 mL/min/m
2
(children and adults)
5–6 mL/kg/min (infants)
Equation:
V
#
CO
2
5 V
#
E 3 FECO
2
V
#
CO
2
5
V
#
A 3 PACO
2
PB 2 PAH
2
O
V
#
A 5
V
#
CO
2
1PB 2 PAH
2
O2
PACO
2
5
RE1PB 2 PAH
2
O2V
#
O
2
PACO
2
where
V
#
e = exhaled minute volume (mL/min STPD)
FECO
2
= fraction of carbon dioxide in mixed exhaled gas
V
#
a = alveolar ventilation (mL/min STPD)
PACO
2
= partial pressure of alveolar carbon dioxide (mm Hg). This value
is often assumed to be equal to arterial carbon dioxide tension
(Paco
2
)
Re = respiratory exchange ratio
Pb = barometric pressure (mm Hg)
PAH
2
O = partial pressure of water in alveolar gas (mm Hg). This value is
47 mm Hg for gas saturated with water vapor at 378C.
During rebreathing experiments or when individuals are confined to an
enclosed area, the carbon dioxide concentration rises in proportion to the
rate of carbon dioxide production. The time required to reach a given carbon
dioxide concentration (% CO
2
) is given by
t 5
% CO
2
3 V
V
#
CO
2
3 100 3 N
84096_CH03_Chatburn.indd 49 6/16/10 6:37:41 AM
50  CHAPTER 3 Physiologic Monitoring
where
t = time
% CO
2
= ambient CO
2
level (%)
V = volume of enclosure
V
#
CO
2
= CO
2
production rate
N = number of individuals
For example, at one time the standard for ambient carbon dioxide levels
aboard Navy submarines was 3%. V
#
CO
2
was estimated at 0.75 ft
3
/h so that
the above equation reduced to t(hours) = 0.04 V/N.
Alveolar Carbon Dioxide Equation
Alveolar partial pressure of carbon dioxide is directly proportional to the
amount of carbon dioxide produced by metabolism and delivered to the lungs
and inversely proportional to the alveolar ventilation. Alveolar and arterial
Pco
2
can be assumed to be equal.
Abbreviation: Paco
2
Units: mmHg
Normal value: 35–45 mm Hg
Equation:
PACO
2
5
0.863 3 V
#
CO
2
V
#
E 3 a1 2
VD
VT
b
where
V
#
CO
2
= carbon dioxide output
V
#
E = exhaled minute ventilation
Vd/Vt = Dead space ratio
Respiratory Quotient
The molar ratio of carbon dioxide production to oxygen consumption. This
ratio depends on the type of substrate being metabolized. For glucose, the
respiratory quotient equals 1.0 (i.e., C
6
H
12
O
2
+ 6 O
2
S 6 COCO
2
+ 6 H
2
O).
For fat RQ is approximately 0.7, and for protein RQ is about 0.8. Under
84096_CH03_Chatburn.indd 50 6/16/10 6:37:41 AM
Gas Exchange  51
steadystate conditions, a mixture of glucose, fat, and protein is metabolized
to produce a respiratory quotient of 0.8–0.85.
Abbreviation: RQ
Units: dimensionless
Normal value: 0.80–0.85
Respiratory Exchange Ratio
The ratio of carbon dioxide output to oxygen uptake as determined by the
analysis of mixed exhaled gas.
Abbreviation: Re
Units: dimensionless
Normal value: 0.8
Equations:
RE 5
V
#
CO
2
V
#
O
2
RE 5
FECO
2
FIO
2
a
1 2 FECO
2
2 FEO
2
1 2 FIO
2
b 2 FEO
2
where
V
#
CO
2
= carbon dioxide output
V
#
O
2
= oxygen uptake
FECO
2
= fraction of carbon dioxide in mixed exhaled gas
FIO
2
= fraction of inspired oxygen
FEO
2
= fraction of oxygen in mixed exhaled gas
Partial Pressure of Inspired Oxygen
The dry gas pressure of oxygen in inspired air.
Abbreviation: Pio
2
Units: mm Hg (torr)
Equation:
PIO
2
5 1PB 2 PIH
2
O2FIO
2
84096_CH03_Chatburn.indd 51 6/16/10 6:37:42 AM
52  CHAPTER 3 Physiologic Monitoring
where
Pb = barometric pressure (mm Hg)
Pih
2
o = partial pressure (mm Hg) of water in inspired gas (This value is
47 mm Hg for gas saturated with water vapor at 378C.)
Fio
2
= fraction of oxygen in inspired gas
Note: To calculate Pio
2
during mechanical ventilation, mean airway pressure
(in mm Hg) should be added to barometric pressure.
Tables 3–1 and 3–2 along with Figures 3–1 through 3–4 show various mea
surements of partial pressure as well as the effects of altitude on such mea
surements.
Table 3–1 Effect of Altitude on Inspired Oxygen Tension
Altitude
Barometric
Pressure
Inspired
Oxygen
Tension
Equivalent
Fio
2
*
(ft) (m) (torr) (kPa) (torr) (kPa)
0 0 760 101 149 20 0.21
1,000 305 733 97 143 19 0.2
2,000 610 707 94 138 18 0.19
3,000 914 681 91 133 18 0.19
4,000 1,219 656 87 127 17 0.18
5,000 1,524 632 84 122 16 0.17
6,000 1,829 609 81 117 16 0.16
8,000 2,438 564 75 108 14 0.15
10,000 3,048 523 70 99 13 0.14
12,000 3,658 483 64 91 12 0.13
14,000 4,267 446 59 83 11 0.12
16,000 4,877 412 55 76 10 0.11
18,000 5,486 379 50 69 9 0.10
20,000 6,096 349 46 63 8 0.09
22,000 6,706 321 43 57 8 0.08
24,000 7,315 294 39 52 7 0.07
26,000 7,925 270 36 47 6 0.07
28,000 8,534 247 33 42 6 0.06
30,000 9,144 226 30 37 5 0.05
*Fio
2
at sea level, which would produce the same inspired oxygen tension.
84096_CH03_Chatburn.indd 52 6/16/10 6:37:42 AM
Gas Exchange  53
Table 3–2 Comparison of BloodGas Values at Altitude and at Sea Level
Sea Level Denver
1609 m
Mt Everest
8400 m
pH 7.35–7.45 7.3.5–7.45 7.457.60
Pco
2
, mm Hg 35–45 34–38 10.3–15.7
Po
2
, mm Hg 80–100 65–75 19.1–29.5
So
2
, % .95 92–94 34–69.7
HCO
2
3
, mEq/L 22–26 22–26 9.9–12
be, mEq/L 22–+2 22–+2 25.7–29.2
Data from Grocott, M. P. W. et al. NEJM 360 (2009), 140–149.
Figure 3–1 Partial pressures of gas in air at sea level (BP = mm Hg).
Blood mm Hg
800
600
400
200
0
Air Artery Alveolus
Vein
CO
2
O 3
H
2
O 10
N
2
592
O
2
157
C
2
102
O
2
40
O
2
93
CO
2
40 CO
2
40 CO
2
47
N
2
570
N
2
570
N
2
570
H
2
O 47 H
2
O 47 H
2
O 47
84096_CH03_Chatburn.indd 53 6/16/10 6:37:42 AM
54  CHAPTER 3 Physiologic Monitoring
Figure 3–2 Normal partial pressures of respired gases.
Inspired Gas
mm Hg (kPa)
Mixed Expired Gas
mm Hg (kPa)
Mixed Venous Blood Gas
mm Hg (kPa)
Arterial Blood Gas
mm Hg (kPa)
ALVEOLAR GAS
mm Hg (kPa)
PIO
2
PICO
2
PIN
2
PIH
2
O
158
0.3
596
5
(21.0)
(0.04)
(79.3)
(0.7)
PaO
2
PaCO
2
PaN
2
90–110
34–46
573
(11.0–14.6)
(4.5–6.1)
(76.2)
PEO
2
PECO
2
PEN
2
PEH
2
O
116
28
568
47
(15.4)
(3.7)
(75.5)
(6.3)
PAO
2
PACO
2
PAN
2
PAH
2
O
103
40
47
570
(137)
(53)
(6.3)
(758)
¯
¯
¯
PVO
2
PVCO
2
PVN
2
37–42
40–52
573
(4.9–5.6)
(5.3–6.9)
(76.2)
¯
¯
¯
¯
84096_CH03_Chatburn.indd 54 6/16/10 6:37:43 AM
Gas Exchange  55
Figure 3–3 The effect of altitute on inspired, alveolar, and arterial oxygen tension
(Fio
2
= 0.21).
h
y
p
o
x
e
m
i
a
PIO
2
PaO
2
PaO
2
PaO
2
PaO
2
PAO
2
severe
mild
moderate
1000 2000 3000 4000 0
150
140
130
120
110
90
80
70
60
50
40
30
20
10
0
2 4 6 8 10 12 14 16
0
2
4
6
8
10
12
14
18
20
16
(
k
P
a
)
Altitude
(thousands of feet)
P
r
e
s
s
u
r
e
(
m
m
H
g
)
(Meters)
100
84096_CH03_Chatburn.indd 55 6/16/10 6:37:43 AM
56  CHAPTER 3 Physiologic Monitoring
Figure 3–4 The effect of altitude on Pao
2
during oxygen administration.
35 25 20 15 12 8 4 0
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
100 200 300 400 500 600 700
Arterial Oxygen Tension
(mm Hg)
Altitude
(thousands of feet above sea level)
F
r
a
c
t
i
o
n
o
f
I
n
s
l
p
i
r
e
d
O
x
y
g
e
n
Alveolar Oxygen Tension
The following equation represents the mean alveolar oxygen tension. Figure
3–5 illustrates a nomogram for the equation.
Abbreviation: Pao
2
Units: mm Hg (torr)
Normal value (room air): 102 at sea level
Equation:
PAO
2
5 PIO
2
2 PACO
2
c FIO
2
1 a
1 2 FIO
2
RE
b d
< PIO
2
2
PACO
2
RE
84096_CH03_Chatburn.indd 56 6/16/10 6:37:43 AM
Gas Exchange  57
where
Pio
2
= partial pressure of oxygen in inspired gas (mm Hg)
Paco
2
= partial pressure (mm Hg) of carbon dioxide in alveolar gas (this
value is often assumed to be equal to arterial carbon dioxide
tension [Paco
2
])
Fio
2
= fraction of oxygen in inspired gas
Re = respiratory exchange ratio
Figure 3–5 Alveolar air equation nomogram (assuming sea level and R = 0.8 and vir
tual shunt of 5%). A straight line connecting Paco
2
and Fio
2
will intersect the resulting
Pao
2
and the predicted Pao
2
. For example, a Paco
2
of 40 mm Hg and an Fio
2
of 70% will
result in a Pao
2
of approximately 450 mm Hg and a predicted Pao
2
of about 370 mm Hg.
FIO
2
PaCO
2
PaO
2
600
550
500
400
300
200
100
100
200
300
400
150
250
350
450
450
350
250
150
80
70
60
50
40
30
20
90 80
70
60
50
40
30
20
90
100
(mm Hg)
(mm Hg)
PAO
2
(mm Hg)
(%)
84096_CH03_Chatburn.indd 57 6/16/10 6:37:43 AM
58  CHAPTER 3 Physiologic Monitoring
Arterial–Alveolar Oxygen Tension Ratio
An index of gas exchange function that has been shown to be more stable
than the alveolar–arterial oxygen tension gradient with changing values of
inspired oxygen concentration. It is most stable when it is less than 0.55, the
Fio
2
is greater than 0.30, and the Pao
2
is less than 100 mm Hg. (For graphs
related to this ratio, see Figures 3–6 and 3–7.)
Abbreviation: P(a/a)o
2
Units: dimensionless
Normal value: 0.74–0.82 (lower limits of normal for men)
Equation:
P1a>A2O
2
5
PaO
2
PIO
2
2 PACO
2
c FIO
2
1 a
1 2 FIO
2
RE
b d
P1a>A2O
2
<
PaO
2
PIO
2
2
PaCO
2
RE
Figure 3–6 Graph relating the expected Pao
2
during oxygen administration based on
the measured Pao
2
on room air.
PaO
2
on air (mm Hg)
P
a
O
2
o
n
O
2
(
m
m
H
g
)
30 40 50 60 70
20
40
60
80
100
40%
35%
28%
24%
84096_CH03_Chatburn.indd 58 6/16/10 6:37:43 AM
Gas Exchange  59
where
Pao
2
= partial pressure of oxygen in arterial blood (mm Hg)
Pio
2
= partial pressure of oxygen in inspired gas (mm Hg)
Paco
2
= partial pressure of carbon dioxide in alveolar gas (mm Hg); this
value is often assumed to be equal to Paco
2
Paco
2
= partial pressure of carbon dioxide in arterial blood
Fio
2
= fraction of oxygen in inspired gas
Re = respiratory exchange ratio
Figure 3–7 Arterial to alveolar oxygen tension ratio nomogram. A straight line con
necting Paco
2
and Fio
2
will intersect the resulting Pao
2
. The arterialalveolar ratio is
represented by the diagonal line connecting the origin of the graph (Pao
2
= 0, Pao
2
= 0)
and the point representing the given Pao
2
and Pao
2
. For example, a Paco
2
of 40 mm Hg
and an Fio
2
of 70% result in a Pao
2
of about 450 mm Hg. If the measured Pao
2
is
225 mm Hg, the P(a/a)o
2
ratio is 0.5.
PaO
2
(mm Hg)
PaO
2
(kPa)
500 600 400 300 200 100 0
PAO
2
PaCO
2
FIO
2
0 10 20 30 40 50 60 70 80
(mm Hg)
PAO
2
(kPa)
(kPa)
PaCO
2
(mm Hg)
(%)
90
80
60
70
40
50
5
10
5
0
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
30
20
60
70
80
90
100
100
50
0
150
200
250
300
350
400
450
500
550
600
40
50
30
20
0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0
84096_CH03_Chatburn.indd 59 6/16/10 6:37:44 AM
60  CHAPTER 3 Physiologic Monitoring
Prediction Equation for Normal P(a/a)O
2
While Breathing Room Air:
Sitting: P(a/a)o
2
= 0.9333 2 0.0026 age (yr)
Supine: P(a/a)o
2
= 0.9333 2 0.00406 age (yr)
The patient’s current P(a/a)o
2
may be used to estimate the Fio
2
required to
obtain a desired Pao
2
using the equation:
FIO
2needed
5
a
PaO
2 desired
P1a>A2O
2
b 1 PaCO
2 desired
PB 2 47
where
Pb = barometric pressure in mm Hg
Alveolar–Arterial Oxygen Tension Gradient
This method of estimating the degree of intrapulmonary shunting assumes
that the arterial oxygen tension is greater than 150 mm Hg. The results of
this calculation are limited to giving only a qualitative estimate of the degree
of shunting and will vary with changes in the inspired oxygen concentration
and cardiovascular status. The alveolar–arterial oxygen gradient increases
with age mainly due to progressing V
#
>Q
#
mismatch.
Abbreviation: P(a–a)o
2
Units: mm Hg
Normal value: 7–14 (while breathing 21% O
2
)
Equation:
P1A–a2O
2
5 PIO
2
2 PACO
2
c FIO
2
1 a
1 2 FIO
2
RE
b d 2 PaO
2
P1A–a2O
2
< PIO
2
2
PACO
2
RE
2 PaO
2
where
Pio
2
= partial pressure of oxygen in inspired gas (mm Hg)
Paco
2
= partial pressure (mm Hg) of carbon dioxide in alveolar gas (this
value is often assumed to be equal to Paco
2
)
84096_CH03_Chatburn.indd 60 6/16/10 6:37:44 AM
Gas Exchange  61
Paco
2
= partial pressure of oxygen in arterial blood (mm Hg)
Fio
2
= fraction of oxygen in inspired gas
Re = respiratory exchange ratio
Note: Another estimate of shunt can be derived by assuming a value for ideal
alveolar–arterial equilibration while breathing 100% oxygen. Under these
conditions, arterial oxygen tension (using normal values) can be expressed as
PaO
2
5 PAO
2
5 PB 2 147 1 PaCO
2
2 < 673 mm Hg
Any reduction in actual arterial oxygen tension from the theoretical value
represents venoustoarterial shunting. For practical purposes, each 100 mm
Hg reduction in actual Pao
2
below the theoretical Pao
2
represents a 5%
shunt. The clinical equation is thus
% shunt <
673 2 PaO
2
20
Prediction Equations for Normal P(a–a)O
2
While Breathing Room Air:
Sitting: P(a–a)o
2
= 0.27 age (yr)
Supine: P(a–a)o
2
= 0.42 age (yr)
Tables 3–3, 3–4, and 3–5 show equations and ranges to characterize the
severity of oxygenation impairment.
Table 3–3 Prediction Equations for Determining Oxygenation Impairment for Sitting
Subjects
Impairment Pao
2
(mm Hg)
P(a–a)o
2
(mm Hg)
P(a/a)o
2
(Dimensionless)
Normal $97.2 2 0.27 age
*
#7 + 0.27 age
*
$0.933 2 0.0026 age
**
Mild $83.2 2 0.27 age
*
#21 + 0.27 age
*
$0.798 2 0.0026 age
**
Moderate $69.2 2 0.27 age
*
#35 + 0.27 age
*
$0.664 2 0.0026 age
**
Severe $55.2 2 0.27 age
*
#49 + 0.27 age
*
$0.482 2 0.0026 age
**
Extreme ,55.2 2 0.27 age
*
.49 + 0.27 age
*
,0.482 2 0.0026 age
**
*
Age in years; for supine posture, change age coefficient to 0.42.
**
Age in years; for supine posture, change age coefficient to 0.00406.
84096_CH03_Chatburn.indd 61 6/16/10 6:37:44 AM
62  CHAPTER 3 Physiologic Monitoring
Table 3–4 Assessment of Hypoxemia in Adults and
Children
*
Pao
2
(mm Hg)
Normal 97
Acceptable .80
Mild hypoxemia ,80
Moderate hypoxemia ,60
Severe hypoxemia ,40
*
Sea level, 21% oxygen.
Table 3–5 Assessment of Hypoxemia in Newborn and
Elderly Patients
*
Age (yr) Acceptable Range of Pao
2
Newborn 40–70
60 .80
70 .70
80 .60
90 .50
*
Limits of hypoxemia for elderly patients are determined by subtract
ing 1 mm Hg for each year over 60.
Normal: Pao
2
< 102 2 0.33 3 age (yr)
Oxygenation Ratio
The ratio of arterial oxygen tension to the fraction of inspired oxygen (where
Fio
2
is expressed as a decimal, 30% = 0.3). A ratio of 200 or less correlates
with a shunt fraction of 20% or more but is generally a crude indicator of
shunt. This ratio is easier to calculate than either the P(a–a)o
2
or the P(a/a)O
2
,
but is subject to variability due to differing values of arterial carbon dioxide
tension.
Abbreviation: Pao
2
/Fio
2
Units: dimensionless
Normal value: 350–470
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Gas Exchange  63
Oxygenation Index
An index of oxygenation status often used to assess infants before treatment
with extracorporeal membrane oxygenation (ECMO). In these patients, an
index value of .35 for 5–6 hours is one criterion for ECMO. The value of
the oxygenation index correlates with mortality in pediatric acute respiratory
failure.
Abbreviation: OI
Units: cm H
2
O/mm Hg
Normal Value: 0
Equation:
OI 5
Paw 3 FIO
2
PaO
2
3 100
where
Paw = mean airway pressure (cm H
2
O)
Fio
2
= fraction of inspired oxygen (as decimal)
Pao
2
= arterial oxygen tension (mm Hg)
Physiologic Dead Space (Bohr Equation)
The volume of inspired gas that is not effective in arterializing the venous
blood. The three main reasons for its ineffectiveness are (1) it never reached
alveoli, (2) it reached alveoli with no perfusion, or (3) too much gas reached
the alveoli in proportion to their perfusion. Physiologic dead space is often
expressed as a ratio of dead space volume to tidal volume (Vd/Vt). Figure
3–8 shows the correlation between minute ventilation and carbon dioxide at
different values of physiologic dead space.
Abbreviation: Vd
Units: mL (BTPS)
Normal value: Vt = 2.2 mL/kg ideal body weight
Vd/Vt = 0.20–0.40
Equation:
VD 5
PACO
2
2 PECO
2
PACO
2
3 VT
84096_CH03_Chatburn.indd 63 6/16/10 6:37:44 AM
64  CHAPTER 3 Physiologic Monitoring
where
Vt = tidal volume (mL BTPS)
Paco
2
= partial pressure (mm Hg) of carbon dioxide in alveolar gas
(this value is often assumed to be equal to arterial carbon
dioxide tension [Paco
2
])
PECO
2
= partial pressure of carbon dioxide in mixed exhaled gas
(mm Hg)
Prediction Equation:
VD
VT
5
actual V
#
E
pred V
#
E
3
PaCO
2
40
3 0.33
where
pred = minute ventilation predicted from Radford nomogram
Paco
2
= arterial carbon dioxide tension (mm Hg)
Figure 3–8 Graph relating minute ventilation and Paco
2
for different values of physi
ologic dead space (assuming Pb = 760 mm Hg, 37°C, and carbon dioxide output of 112
mL/min/m
2
).
PaCO
2
(mm Hg)
PaCO
2
(kPa)
M
i
n
u
t
e
V
e
n
t
i
l
a
t
i
o
n
(
L
/
m
i
n
/
s
q
u
a
r
e
m
e
t
e
r
)
30
20
10
0
3 4 5 6
(%)
7 8 9 10
20
20
30
30
40
40
50
50
60
60
70
70
80
80
VD
VT
84096_CH03_Chatburn.indd 64 6/16/10 6:37:45 AM
Gas Exchange  65
Clinical Calculation of Dead Space
Classically, to calculate dead space requires collection of exhaled gas to
measure the partial pressure of carbon dioxide. This is technically difficult
in daily practice, although there are devices that can obtain approximations
based on volume exhaled and the curve obtained from the end tidal carbon
dioxide, this is also not widely available. Recently Frankenfield et al. (Crit
Care Med 38 (2010), 288–329) described and validated an equation to obtain
the dead space ratio from clinically available data.
Abbreviation: Vd/Vt
Units: dimensionless
Normal value: Vd/Vt = 0.20–0.40
Equation:
VD
VT
5 0.32 1 0.01061PaCO
2
2 ETCO
2
2 1 0.0031RR2 1 0.00151age2
where
Paco
2
= arterial carbon dioxide tension (mm Hg)
ETco
2
= exhaled end tidal carbon dioxide (mm Hg)
RR = respiratory rate (breaths per minute)
Age = age of patient (years)
Oxygen Content of Blood
The following equations give the total quantity of oxygen in the blood. This
includes the quantity of oxygen dissolved in the plasma plus the quantity of
oxygen bound to the hemoglobin.
Abbreviations: Cao
2
(arterial oxygen content)
CVO
2
(mixed venous oxygen content)
Cc9o
2
(pulmonary end capillary oxygen content)
Units: vol% (mL O
2
/dL blood)
Normal value: Cao
2
= 20; CVO
2
= 15
84096_CH03_Chatburn.indd 65 6/16/10 6:37:45 AM
66  CHAPTER 3 Physiologic Monitoring
Equations:
Cao
2
= (Hb 3 1.34 3 O
2
sat) + (0.0031 3 Pao
2
)
CVO
2
= (Hb 3 1.34 3 O
2
sat) + (0.0031 3 PVO
2
)
Cc9o
2
= (Hb 3 1.34 3 O
2
sat) + (0.0031 3 Pc9o
2
)
where
Hb = hemoglobin content in g % (g Hb/dL blood) (normal value =
15 g %)
1.34 = a constant describing the amount of oxygen (mL at STPD)
that can be carried by 1 g Hb when it is fully saturated (some
authorities use 1.39 or 1.36)
O
2
sat = hemoglobin saturation expressed in decimal form. This value
is assumed to be 1.0 when the oxygen tension of the blood is
above 150 mm Hg.
0.0031 = a constant derived using the Bunsen solubility coefficient of
oxygen in blood (i.e., for each 100 mL of blood, 0.0031 mL of
oxygen can be dissolved for each mm Hg of oxygen tension on
the blood)
Pao
2
= partial pressure of oxygen in arterial blood (mm Hg)
PVO
2
= partial pressure of oxygen in mixed venous blood (mm Hg)
Pc9o
2
= partial pressure of oxygen in endpulmonary capillary blood
(mm Hg) (often assumed to be equal to the partial pressure of
oxygen in alveolar gas (Pao
2
))
Note: The pulmonary end capillary oxygen content reflects the maximal oxy
gen carrying capacity, where the oxygen saturation is assumed to be 100%.
Arteriovenous Oxygen Content Difference
The difference between the arterial and venous oxygen content is an indi
cation of the amount of oxygen the body is consuming. It is also used as
an indication of cardiac output. That is, if the metabolic demands of the
body are assumed to be constant, a decrease in cardiac output will cause an
increase in arteriovenous oxygen difference.
Abbreviation: C(a–V)O
2
Units: vol% (mL O
2
per dL blood)
84096_CH03_Chatburn.indd 66 6/16/10 6:37:45 AM
Gas Exchange  67
Normal value: 4.5–6.0 (children and adults)
2.5–4.5 (patients that are critically ill but stable)
Equation:
C1a 2 V2O
2
5 CaO
2
2 CVO
2
where
Cao
2
= arterial oxygen content (mL/dL)
CVO
2
= mixed venous oxygen content (mL/dL)
Ventilation–Perfusion Ratio
This equation relates the factors that determine the adequacy of alveolar
ventilation. It assumes that arterial and mixed venous blood gas samples are
drawn simultaneously. This should be done midway through the expired gas
collection if Re is being calculated.
Abbreviation: V
#
>Q
#
Units: dimensionless
Normal value: 0.8
Equation:
V
#
A>Q
#
C 5
RE1PB 2 PAH
2
O2 1CaO
2
2 CVO
2
2
PACO
2
3 100
where
V
#
A = alveolar ventilation
Q
#
C = pulmonary blood flow
Re = respiratory exchange ratio
Pb = barometric pressure (mm Hg)
Pah
2
o = partial pressure (mm Hg) of water in alveolar gas (this value is
47 mm Hg for gas saturated with water vapor at 378C)
Cao
2
= arterial oxygen content (mL/dL)
CVO
2
= mixed venous oxygen content (mL/dL)
Paco
2
= partial pressure (mm Hg) of alveolar carbon dioxide (this value
is often assumed to be equal to arterial CO
2
tension [Paco
2
])
84096_CH03_Chatburn.indd 67 6/16/10 6:37:46 AM
68  CHAPTER 3 Physiologic Monitoring
VenoustoArterial Shunt (Classic Form)
The collection of data for the shunt calculation is usually done with the
patient placed supine while breathing 100% oxygen.
Abbreviation: Q
#
S>Q
#
T
Units: %
Normal value: 2–5 (children and adults)
Equation:
Q
#
S
Q
#
T
5
Cc¿O
2
2 CaO
2
Cc¿O
2
2 CvO
2
where
Q
#
S = shunted portion of cardiac output
Q
#
T = total cardiac output
Cc9o
2
= oxygen content of pulmonary endcapillary blood (mL/dL)
Cao
2
= oxygen content of arterial blood (mL/dL)
CVO
2
= mixed venous oxygen content (mL/dL)
VenoustoArterial Shunt (Clinical Form)
The clinical shunt equation is a rearrangement of the classic Q
#
S>Q
#
T equa
tion, with the assumption that arterial hemoglobin is fully saturated with
oxygen when the arterial oxygen tension is greater than 150 mm Hg. This
assumption is valid because the test is done with an inspired oxygen fraction
of 1.0, which usually results in an arterial oxygen tension greater than 150
mm Hg. In most circumstances in which this form of the equation is used,
the arteriovenous content difference, C(a–V2O
2
is assumed to be 3.5 vol%.
Figure 3–9 shows the relations between arterial blood tension and inspired
oxygen concentration for different values of shunt. Table 3–6 shows “nor
mal” values for respiratory gas exchange.
Abbreviation: Q
#
S>Q
#
T
Units: %
Normal value: 2–5 (children and adults)
84096_CH03_Chatburn.indd 68 6/16/10 6:37:46 AM
Gas Exchange  69
Equation:
Q
#
S
Q
#
T
5
1PAO
2
2 PaO
2
20.0031
C1a–V2O
2
1 1PAO
2
2 PaO
2
20.0031
where
Q
#
S = shunted portion of cardiac output
Q
#
T = total cardiac output
Pao
2
= partial pressure of oxygen in alveolar gas (mm Hg)
Pao
2
= partial pressure of oxygen in arterial blood (mm Hg)
0.0031 = a constant derived using the Bunsen solubility coefficient for
oxygen in blood (i.e., for each 100 mL of blood at BTPS,
0.0031 mL of oxygen can be dissolved for each 1.0 mm Hg of
oxygen tension)
C(a–V)o
2
= arteriovenous oxygen content difference (mL/dL)
Figure 3–9 Graph relating Pao
2
and inspired oxygen concentration for different values
of virtual shunt. Shaded lines represent hemoglobin concentration range of 10–14 g/dL
and Paco
2
range of 25–40 mm Hg (3.3–5.3 kPa).
Virtual Shunt
400
300
200
100
0 0
10
20
30
40
50
60
20 30 40 50 60 70 80 90 100
Inspired Oxygen Concentration (%)
10%
15%
20%
25%
30%
50%
5% 0%
A
r
t
e
r
i
a
l
O
x
y
g
e
n
T
e
n
s
i
o
n
kPa mmHg
84096_CH03_Chatburn.indd 69 6/16/10 6:37:46 AM
70  CHAPTER 3 Physiologic Monitoring
Table 3–6 Respiratory Gas Exchange and Pressures
Measurement Symbol Adult Infant Units
Flows
Alveolar ventilation (Va) 60 120 mL/kg/min
Pulmonary capillary flow (Qc) 75 200 mL/kg/min
Ventilation–perfusion ratio (V/Q) 0.8 0.6
Venous admixture
Shunt flow/total flow Qs/Qt 0.05 0.05–0.15
Alveolar gases
Oxygen (Pao
2
) 105 105 mm Hg
Carbon dioxide (Paco
2
) 40 35 mm Hg
Nitrogen (Pan
2
) 568 573 mm Hg
Arterial gases
Oxygen (Pao
2
) 95 80 mm Hg
Carbon dioxide (Paco
2
) 41 36 mm Hg
Nitrogen (Pan
2
) 575 583 mm Hg
Gas differences
Oxygen P(a–a)o
2
10 24 mm Hg
Carbon dioxide P(a–a)co
2
1 1 mm Hg
Nitrogen P(a–a)n
2
7 10 mm Hg
Equations for Human BloodOxygen Dissociation
Computation
The following equations assume blood temperature = 378C and pH = 7.40.
Oxygen Saturation (So
2
, as a Decimal Fraction) from Oxygen Tension
(Po
2
, in mm Hg):
SaO
2
5 1 fPO
3
2
1 150 3 PO
2
2
21
3 23,400g 1 12
21
(3–1)
Po
2
from So
2
(for So
2
, 0.96):
PO
2
5 exp c 0.385 3 ln1SO
21
2
2 12
21
1 3.32 2 172 3 SO
2
2
21
2
1SO
2
2
6
6
d
(3–2)
.
.
. .
. .
84096_CH03_Chatburn.indd 70 6/16/10 6:37:47 AM
Gas Exchange  71
where
ln represents the natural logarithm (i.e., log
e
)
Correction of Po
2
to pH = 7.40 (Bohr Effect):
PO
2
1at 7.402 5 PO
2
3 e
1.131pH27.42
(3–3)
Computation of P
50
:
Step 1: Obtain a sample of blood with a measured saturation between 0.2
and 0.8.
Step 2: Measure the Po
2
and pH of the sample at 378C.
Step 3: Use equation (3–2) above to calculate Po
2
from the measured So
2
;
use this value as Po
2
(std) in equation (3–4) below.
Step 4: Use equation (3–3) above to estimate Po
2
at pH = 7.4 from the
measured Po
2
and pH; use this value as Po
2
(obs) in equation
(3–4) below.
Step 5: P
50
5
26.7 3 PO
2
1obs2
PO
2
1std2
(3–4)
Hemoglobin Affinity for Oxygen
(See Figure 3–10 and Figure 3–11.) Factors shifting the hemoglobinoxygen
dissociation curve to the right (decreased affinity):
1. Acidemia
2. Hyperthermia
3. Hypercarbia
4. Increased 2,3diphosphoglycerate (2,3DPG)
Factors shifting the hemoglobinoxygen dissociation curve to the left
(increased affinity):
1. Alkalemia
2. Hypothermia
3. Hypocarbia
4. Decreased 2,3DPG
84096_CH03_Chatburn.indd 71 6/16/10 6:37:47 AM
72  CHAPTER 3 Physiologic Monitoring
Figure 3–10 Nomogram relating Po
2
and oxygen saturation (So
2
) at 37°C, pH = 7.40,
and base excess = 0.
PO
2
SO
2
200
100
100
200
20.0
10.0
8.0
7.0
6.0
5.0
4.0
3.0
2.0
6.5
5.5
4.5
3.5
2.5
1.5
400
700
110
130
150
100
95
85
75
65
70
60
80
90
70
60
50
50
30
20
15
14
13
12
11
10
9
8
40
30
45
35
25
15
20
(mm Hg) (%)
PO
2
SO
2
(mm Hg) (%)
PO
2
SO
2
(kPa) (%)
PO
2
SO
2
(kPa) (%)
50
40
30
20
10
60
70
80
90
100
99
98
97
96
95
94
93
92
91
100
99
98
97
96
95
94
93
92
91
100 100
90
80
70
60
50
40
30
20
10
84096_CH03_Chatburn.indd 72 6/16/10 6:37:47 AM
BloodGas Analysis: Traditional and the Stewart Method  73
BloodGas analysis: TradiTional and ThE ■
sTEwarT METhod
Henderson–Hasselbalch Equation
This equation expresses the blood acid–base relationship in terms of the
bicarbonate ion to carbonic acid ratio. It is based on the chemical equation
H
2
CO
3
SH
1
1 HCO
2
3
which describes the dissociation of carbonic acid into hydrogen ions and
bicarbonate ions. The law of mass action defines the dissociation constant
(K
a
) of carbonic acid as
K
a
5
fH
1
g fHCO
2
3
g
fH
2
CO
3
g
The carbonic acid concentration is dependent on the amount of dissolved car
bon dioxide in the blood. The amount of dissolved carbon dioxide (mmol/L)
is dependent on its solubility coefficient (0.03 mmol/L/mm Hg) and the par
tial pressure of carbon dioxide in the blood (Pco
2
) (see Figure 3–16). Thus,
Adult
600 500 400 300 200 100
Oxygen Tension (mm Hg)
10 20 30 40 50 60 70 80 90
Fetal
100
85
80
75
60
40
20
%
O
x
y
g
e
n
S
a
t
u
r
a
t
i
o
n
Dangerous
to infant
retina
Adult
Fetal
O
2
tensions of
which cyonosis
first observed
Figure 3–11 Oxyhemoglobin dissociation curves. P
50
: An index of the affin
ity of hemoglobin for oxygen. It is defined as the oxygen tension at which
50% of the hemoglobin is saturated at 37°C, Pco
2
= 40 mm Hg, and pH = 7.4.
The normal adult P
50
is approximately 27 mm Hg. A reduced P
50
means an
increased hemoglobin affinity for oxygen.
84096_CH03_Chatburn.indd 73 6/16/10 6:37:47 AM
74  CHAPTER 3 Physiologic Monitoring
the above equation can be written as
K
a
5
fH
1
g fHCO
2
3
g
0.03PCO
2
This equation can now be rearranged to a more useful form that relates
plasma hydrogen ion concentration, PCO
2
, and bicarbonate concentration, all
measurable quantities:
fH
1
g 5 K
a
a
0.03PCO
2
fHCO
2
3
g
b
The hydrogen ion concentration is more commonly expressed in terms of pH
(negative log of hydrogen ion concentration) as follows:
2log fH
1
g 5 2log K
a
2 log a
0.03PCO
2
fHCO
2
3
g
b
pH 5 2 log K
a
1 log a
fHCO
2
3
g
0.03PCO
2
b
The value of 2log K
a
(i.e., PK
a
) is 6.1. Substituting normal values for HCO
2
3
(24 mmol/L) and Paco
2
(40 mm Hg) in the above equation yields
pH 5 6.1 1 log a
24
0.03 3 40
b
5 6.1 1 1.3
6 normal pH 5 7.4.
Table 3–7 shows the ranges for pH and Paco
2
at sea level. Table 3–8 shows
the formulas used to calculate the expected compensation in simple acid–base
disorders. Figures 3–12, 3–13, 3–14, and 3–15 depict nomograms, flow charts,
and maps to interpret acid–base disorders.
Table 3–7 Ranges and Nomenclature for pH and Paco
2
pH Paco
2
(mm Hg)
Normal range
Mean 7.40 40
1 SD 7.38–7.42 38–42
2 SD 7.35–7.45 35–45
Alkalemia $7.46
Acidemia #7.34
84096_CH03_Chatburn.indd 74 6/16/10 6:37:48 AM
BloodGas Analysis: Traditional and the Stewart Method  75
Table 3–8 Expected Compensation for Simple Acid–Base Disorders
Disorder and
Compensation
pH Initial Change Compensatory
Change
Anion
Gap
Metabolic acidosis
T
T HCO
–
3
T Paco
2
N, c
Paco
2
= (1.5 3 HCO) + 8 ; 2
Paco
2
< last two digits of pH
Paco
2
T 1.0–1.5 torr/ T 1.0 mEq/L HCO
–
3
Metabolic alkalosis
c c HCO
–
3 c
Paco
2
N, T
Paco
2
= (0.7 3 HCO
–
3
) + 21
Paco
2
= 40 + (0.6 3 standard base excess)
Paco
2
c 0.5–1.0 torr/ c 1 mEq/L HCO
–
3
Respiratory acidosis
T
c Paco
2
c HCO
–
3
N
Acute (,24 h)
DH
+
= 0.8 3 DPaco
2
DpH = 0.008 3 DPaco
2
HCO
–
3
= ([Paco
2
2 40]/10) + 24
HCO
–
3
c 0.1–1.0 mEq/L/ c 10 torr Paco
2
Chronic (.24 h)
DH
+
= 0.3 3 DPaco
2
DpH = 0.003 3 DPaco
2
HCO
–
3
= ([Paco
2
2 40]/3) + 24
HCO
–
3
c 1.1–3.5 mEq/L/ c 10 torr Paco
2
Respiratory alkalosis
c
T Paco
2
T HCO
–
3
N, c
Acute (,12 h)
DH
+
= 0.8 3 DPaco
2
HCO
–
3
= 24 2([40 2 Paco
2
]/5)
HCO
–
3
T 0–2.0 mEq/L/ T 10 torr Paco
2
Chronic (12–72 h)
DH
+
= 0.17 3 DPaco
2
HCO
–
3
= 24 2([40 2 Paco
2
]/2)
HCO
–
3
T 2.1–5.0 mEq/L/ T 10 torr Paco
2
84096_CH03_Chatburn.indd 75 6/16/10 6:37:48 AM
Figure 3–12 Modified SiggaardAnderson nomogram relating blood pH, bicarbonate
concentration (HCO
–
3
), and Pco
2
.
PCO
2
pH
HCO
3
10
100
110
120
150
20
20
25
15
10
9
8
7
6
5
4
3
30
35
40
50
60
25
30
40
50
60
70
80
90
35
15
8.0
7.9
7.8
7.7
7.6
7.5
7.4
7.3
7.2
7.1
7.0
6.9
6.8
6.7
6.6
1.5
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10
12
14
16
18
2.5
3.5
4.5
(mm Hg) (kPa) (mEq/L)
_
Figure 3–13 Flow chart illustrating a simplified acidbase interpretation scheme.
No
No
No
No No No
No No No
No
No
No
Start
pH
low
pH
high
Mixed
respiratory
and
metabolic
acidosis
Mixed
respiratory
and
metabolic
alkalosis
Compensated
respiratory
acidosis
or
Compensated
metabolic
alkalosis
Compensated
metabolic
acidosis
or
Compensated
respiratory
alkalosis
Partly
compensated
metabolic
acidosis
Partly
compensated
metabolic
alkalosis
Partly
compensated
respiratory
acidosis
Partly
compensated
respiratory
alkalosis
Uncompensated
metabolic
acidosis
Uncompensated
metabolic
acidosis
Uncompensated
respiratory
acidosis
Uncompensated
respiratory
alkalosis
PCO
2
high
PCO
2
low
HCO
3
low
HCO
3
low
HCO
3
high
HCO
3
high
HCO
3
high
Yes Yes
Yes
Yes Yes
Yes
Yes
Yes
Yes Yes
Yes
Yes
Normal
PCO
2
high
PCO
2
low
HCO
3
low
84096_CH03_Chatburn.indd 76 6/16/10 6:37:48 AM
Figure 3–15 An acidbase map for neonates. RMA = mixed respiratory and metabolic
acidosis; N = normal acidbase status; CRA = compensated respiratory alkalosis; CMA =
compensated metabolic alkalosis; RA = respiratory alkalosis.
100 90 80 70 60 50 40 30 20 10 0
0 1 2 3 4 5
Partly
Compensated
Metabolic
Acidosis
Partly
Compensated
Respiratory
Acidosis
7 8 9 10 11 12 13 6
PCO
2
(kPa)
PCO
2
(mm Hg)
H
+
(nM/L)
pH
100
90
80
70
60
50
40
30
20
10
7.0
7.1
7.2
7.3
7.4
7.5
7.6
7.7
8.0
Compensated
Metabolic
Acidosis
Metabolic Alkalosis
with
Respiratory Acidosis
Mixed
Respiratory
and Metabolic
Alkalosis
Respiratory
Acidosis
RA
CRA
CMA
N
RMA
18 24
M
e
t
a
b
o
l
i
c
A
l
k
a
l
o
s
i
s
M
e
t
a
b
o
l
i
c
A
c
i
d
o
s
i
s
Compensated
Respiratory
Acidosis
HCO
3
_
Mixed
Respiratory
and Metabolic
Acidosis
Respiratory
Alkalosis
with
Metabolic
Acidosis
Figure 3–14 An acidbase map for children and adults. N = normal acidbase status;
CRA = chronic respiratory alkalosis; ARA = acute respiratory alkalosis.
100 90 80 70 60 50 40 30 20 10 0
0 1 2 3 4 5 7 8 9 10 11 12 13 6
C
h
r
o
n
i
c
R
e
s
p
.
A
c
i
d
o
s
i
s
Metabolic
Alkalosis
N
CRA
A
R
A
M
e
t
a
b
o
l
i
c
A
c
i
d
o
s
i
s
PCO
2
(kPa)
PCO
2
(mm Hg)
H
+
(nM/L)
pH
H
C
O
3
m
E
q
/
L
A
c
u
t
e
R
e
s
p
.
A
c
i
d
o
s
i
s
6 9 12 15 18 21 24
100
90
80
70
60
50
40
30
20
10
27
30
33
36
48
57
69
75
7.0
7.1
7.2
7.3
7.4
7.5
7.6
7.7
8.0
42
84096_CH03_Chatburn.indd 77 6/16/10 6:37:49 AM
78  CHAPTER 3 Physiologic Monitoring
Anion Gap
The anion gap is used to evaluate the nature of a metabolic acidosis. In dis
ease states characterized by elevated organic acids, the anion gap increases.
The anion gap decreases 2.3 to 2.5 mEq/L for every 1 g/dL albumin reduc
tion in plasma.
Abbreviation: AG
Units: mEq/L
Normal value: 15–20
Equations:
AG = (Na
+
+ K
+
) – (Cl
–
+ HCO
2
3
)
Figure 3–16 Components of carbon dioxide curve for whole blood.
as dissolved CO
2
PCO
2
(mm Hg)
C
O
2
c
o
n
t
e
n
t
(
m
l
/
1
0
0
m
l
)
30
25
15
5
20
10
0 20 40 60 80
B
l
o
o
d
c
a
r
b
o
n
d
i
o
x
i
d
e
c
o
n
t
e
n
t
(
m
m
o
l
/
l
)
As bicarbonate ion
in plasma and
erythrocytes
Arterial
point
Mixed
venous
point
Carbamino CO
2
in arterial
blood
Carbamino CO
2
in venous blood
60
50
40
30
20
10
0
84096_CH03_Chatburn.indd 78 6/16/10 6:37:49 AM
BloodGas Analysis: Traditional and the Stewart Method  79
or
AG = Na
+
– (Cl
–
+ HCO
2
3
) (normal range 8–12)
or
adjAG = [(Na
+
+ K
+
) 2 (Cl
–
+ HCO
2
3
) + (2.5 3 ([normal albumin] 2
[observed albumin]))
or
AGc = ([Na
+
+ K
+
] 2 [Cl
–
+ HCO
2
3
)] 2 ([2 3 albumin] +
[0.5 3 phosphate]) 2 lactate (normal range is 0)
where
adjAG = albuminadjusted anion gap
AGc = anion gap corrected
Na
+
= serum sodium concentration (mEq/L)
K
+
= serum potassium concentration (mEq/L)
Cl
–
= serum chloride concentration (mEq/L)
HCO
2
3
= serum bicarbonate concentration (mEq/L)
Albumin (g/dL)
Phosphate (mg/dL)
Lactate (md/dL)
Delta–Delta Gap
A ratio used to evaluate mixed acid–base disorders. It is based on the buffer
concept that for every molecule of acid added to the extracellular fluid, the
acid will react with HCO
2
3
to produce water and CO
2
. Hence, one expects
that for every acid molecule produced, one bicarbonate molecule should
decrease. Note: The ratio depends on how the acid is buffered. Lactic acid
ratio is 1.6/1, and ketones 1:1.
Abbreviation: D/D
Units: mEq/L
Normal value: 1–2
84096_CH03_Chatburn.indd 79 6/16/10 6:37:49 AM
80  CHAPTER 3 Physiologic Monitoring
Equation:
D>D 5
AG
measured
2 AG
normal
HCO
3
2
normal
2 HCO
3
2
measured
where
AG = anion gap (mEq/L)
HCO
2
3
= serum bicarbonate concentration (mEq/L)
Base Excess
The amount of acid or base that must be added to a sample of whole blood in
vitro to restore the pH to 7.40 while the Paco
2
is held at 40 mmHg. It repre
sents the quantity of metabolic acidosis or alkalosis. To enhance the behavior
of the formula in vivo, the standard base excess (SBE) standardizes the effect
of hemoglobin on CO
2
titration. Further corrections (corrected SBE) take
into account albumin and phosphate yielding the closest behavior to actual
physiology.
Abbreviation: BE, SBE, and SBEc
Units: mEq/L
Normal value: ;2
Equations:
BE 5 1HCO
2
3
2 24.4 1 f2.3 3 Hb 1 7.7g 3 fpH 2 7.4g2 3
11 2 0.023 3 Hb2
or
SBE 5 0.9287 3 1HCO
2
3
2 24.4 1 f2.3 3 Hb 1 14.83 3 fpH 2 7.4g2
or
SBEc 5 1HCO
2
3
2 24.42 1 1 f8.3 3 albumin 3 0.15g
1 f0.29 3 phosphate 3 0.32g2 3 1pH 2 7.42
where
BE = base excess (mEq/L)
SBE = standard base excess (mEq/L)
84096_CH03_Chatburn.indd 80 6/16/10 6:37:50 AM
BloodGas Analysis: Traditional and the Stewart Method  81
HCO
2
3
= serum bicarbonate concentration (mEq/L)
Hb = hemoglobin (mmol/L) (1 mmol/L = 0.1 mg/dL Hb)
pH = power of hydrogen (dimensionless)
Albumin (g/dL)
Phosphate (mg/dL)
Stewart Approach to Acid–Base Disorders
Peter A. Stewart introduced in 1981 an alternative view to the interpreta
tion of acid–base theory. His view expressed that acid–base physiology has
independent and dependent variables. The dependent variables ([H
1
], [OH
2
],
[HCO
2
3
], [CO
3
22
], [HA], [A
2
]) are controlled by the independent variables
(Pco
2
, total weak nonvolatile acids and the strong ion difference). Thus,
departing from the concept that HCO
2
3
and pH are controlled directly, and
establishing the mathematical bases to explain the control by the independent
variables.
There are six equations that describe the interactions between dependent and
independent variables:
1. Water dissociation equilibrium
[H
1
] 3 [OH
2
] = K9
w
2. Weak acid dissociation equilibrium
[H
1
] 3 [A
2
] = K
a
x [HA]
3. Conservation of mass for A
[A
TOT
] = [HA] + [A
2
]
4. Bicarbonate ion formation equilibrium
[H
1
] 3 [HCO
3
2
] = K9
1
3 S 3 Pco
2
5. Carbonate ion formation equilibrium
[H
1
] 3 [CO
3
22
] = K
3
3 [HCO
3
2
]
6. Electrical charge equation
[SID
1
] = [HCO
3
2
] + [A
2
] + [CO
3
22
] + [OH
2
] 2 [H
1
]
84096_CH03_Chatburn.indd 81 6/16/10 6:37:50 AM
/) s :?8GK<I* G_pj`fcf^`ZDfe`kfi`e^
where
[A
] = dissociated weak acid concentration, mostly albumin and
phosphate
[HA] = concentration of weak acid associated with a proton
K
w
= autoionization constant for water
K
a
= weak acid dissociation constant for HA
[Atot] = total concentration of weak nonvolatile acids, inorganic phos
phate, serum proteins, and albumin
K
1
= apparent equilibrium constant for the Henderson–Hasselbach
equation
S = solubility of CO
2
in plasma
K
3
= apparent equilibrium dissociation constant for bicarbonate
SID
= strong ion difference (see below)
Strcnç !cn Difference (S!D)
The difference in strong ions ([Na
+ K
] [Cl
+ lactate]). In practice, this
is incalculable because we are unable to measure all strong ions. However,
calculations to obtain the apparent and the effective difference are available.
The apparent SID is directly calculated from available strong cations and
anions in blood. The effective SID (conceptually the same as the known buf
fer base) is calculated with the CO
2
, albumin, and phosphate.
Abbreviation: [SID
]
a
and [SID
]
e
Units: mEq/L
Normal value: SID = 40 mEq
Equations:
F SID
G
a
FNa
G FK
G FMg
G FCa
G FCl
G
FlactateG Fother strong anionsG
FSID
G
e
FHCO
3
G FAA
G
where
Mg
= ionized magnesium concentration (mEq/L)
Ca
= ionized calcium (mEq/L)
[A
] = concentration of dissociated weak noncarbonic acids, principally
albumin and phosphate
BloodGas Analysis: Traditional and the Stewart Method  83
Strong Ion Gap (SIG)
The difference between the effective and apparent SID. The SIG may better
represent the amount of unmeasured anions, when compared to the anion
gap. A particular example is when the albumin is low, the SIG may be high
(a manifestation of unmeasured anions) while the anion gap is normal.
Abbreviation: SIG
Units: mEq/L
Normal value: 0
Equation:
SIG 5 fSID
1
g
a
2 fSID
1
g
e
Based on these concepts, acid–base disorders can be classified using the
independent variables (Paco
2
and Atot and SID). See Table 3–9.
Table 3–9 Classification of AcidBase Disorders Based on Stewart Independent
Variables
Respiratory
Changes in Paco
2
produce expected changes in [H
+
]
Metabolic
1.
Change in [SID]
a.
Change in concentration
i.
Dehydration: Concentrates alkalinity and increases [SID]
ii.
H
2
0 overload: Dilutes alkalinity and decreases [SID]
b.
Changes in strong ion concentrations
i.
Inorganic acids: Increase in chloride (low [SID] and low SIG)
ii.
Organic acids: Accumulation of lactate, formate, or ketones (low [SID] and
high SIG)
2.
Change in [Atot]
Changes in concentration of phosphate, albumin, and other plasma proteins.
Data from Corey, H. E. et al. Critical Care 9 (2005), 184–192.
84096_CH03_Chatburn.indd 83 6/16/10 6:37:50 AM
84  CHAPTER 3 Physiologic Monitoring
hEModynaMics ■
Cardiac Output
Cardiac output equals heart rate times stroke volume. Thus, cardiac output
may be increased by increasing either heart rate or stroke volume. Increasing
the heart rate is the most rapid method of increasing cardiac output, which
can double or triple in a healthy person.
Abbreviation: CO
Unit: L/min
Normal value: 4.0–8.0 (adults); cardiac output for all patients can be
found by multiplying normal cardiac index by body surface area
(BSA).
Cardiac Output (Fick Principle)
This equation is valid if two blood samples (arterial and mixed venous blood)
are drawn simultaneously during mixed expired gas collection and assume a
steady state of ventilation and circulation.
Abbreviation: Q
#
Units: L/min
Normal value: 4.0–8.0 (adult)
Equation:
Q
#
5
V
#
O
2
1CaO
2
2 CVO
2
2 3 10
where
V
#
O
2
= (mL/min STPD)
Cao
2
= arterial oxygen content (mL/dL)
CVO
2
= mixed venous oxygen content (mL/dL)
Cardiac Index
Cardiac output varies with body size and has been shown to increase in pro
portion to the surface area of the body. The cardiac index (cardiac output per
square meter of BSA) is therefore useful in comparing the cardiac outputs
of differentsized people. All flowrelated hemodynamic variables can be
indexed by substituting cardiac index for cardiac output in their equations.
84096_CH03_Chatburn.indd 84 6/16/10 6:37:51 AM
Hemodynamics  85
Abbreviation: CI
Units: L/min/m
2
Normal value: 2.7–4.5 (children and adults)
Equation:
CI = CO/BSA
where
CO = cardiac output (L/min)
BSA = body surface area (m
2
)
Stroke Volume
The volume that the left ventricle ejects with each contraction. It is influ
enced by (1) cardiac contractility, (2) ventricular enddiastolic volume (pre
load), and (3) impedance to left ventricular outflow (afterload).
Abbreviation: SV
Units: mL/beat
Normal value: 60–130 (adults)
Equation:
SV 5
CO 3 1000
HR
where
CO = cardiac output (L/min)
HR = heart rate (bpm)
Stroke Index
Abbreviation: SI
Units: mL/beat/m
2
Normal value: 30–50 (children and adults)
Equation:
SI 5
CI 3 1000
HR
84096_CH03_Chatburn.indd 85 6/16/10 6:37:51 AM
86  CHAPTER 3 Physiologic Monitoring
where
CI = cardiac index (L/min/m
2
)
HR = heart rate (bpm)
Mean Arterial Pressure
The average blood pressure. It represents the force that drives the blood
through the systemic circulatory system. Thus, it is this parameter that is
important from the perspective of tissue blood flow. The mean arterial pres
sure is directly proportional to the cardiac output and the systemic vascular
resistance. Any change in cardiac output (provided the resistance stays
constant), either by stroke volume or heart rate, will cause a corresponding
change in mean arterial pressure.
Abbreviation: MAP
Units: mm Hg
Normal value: 82–102 (adults)
Equations:
MAP > 1/3(systolic 2 diastolic) + diastolic
or
MAP >
1systolic 1 2 3 diastolic2
3
or
MAP 5 1CO 3 SVR2 1 CVP
where
CO = cardiac output (L/min)
SVR = systemic vascular resistance
CVP = central venous pressure
Central Venous Pressure
Abbreviation: CVP
Units: mm Hg
Normal value: 1–7 (adults)
84096_CH03_Chatburn.indd 86 6/16/10 6:37:51 AM
Hemodynamics  87
Table 3–10 Hemodynamic Parameters
Intracardiac Pressure
Values Location
Pressure
*
(mm Hg)
Right atrium
Mean 22–6
Right ventricle
Systolic 14–38
Diastolic 0–7
Pulmonary artery
Systolic 12–28
Diastolic 4–12
Mean 6–18
Pulmonary artery occlusion pressure
Mean 6–12
Left atrium
Mean 6–12
Left ventricle
Systolic 81–141
Diastolic 3–11
*
Based on normal patients aged 2 months to 20 years.
Vascular Resistance
The opposition to blood flow in a vessel. Vascular resistance cannot be
measured directly but is calculated from measurements of blood flow and
pressure. Resistance is defined as
R 5 DP>Q
#
where
R = resistance
DP = the difference in pressure between two points in a vessel
Q
#
= the flow of blood through a vessel
84096_CH03_Chatburn.indd 87 6/16/10 6:37:51 AM
88  CHAPTER 3 Physiologic Monitoring
When DP = 1 mm Hg and flow is 1 mL/sec, then R is said to be 1 resistance
unit. Resistance may also be expressed as a basic physical unit in the centi
metergramsecond (CGS) system of measurement. The units of resistance
in this system are dyne ? s/cm
5
and may be calculated from pressure and flow
measurements by the following formula:
dyne? s>cm
5
5
113332 1mm Hg2
mL>s
5
179.922 1mm Hg2
L>min
where
1333 = the factor to convert mm Hg to dyne/cm
2
To convert from “units” to dyne? s>cm
5
, simply multiply the number of units
by 79.92 (80 is not used in most texts).
Systemic Vascular Resistance
Abbreviation: SVR
Normal value: 900–1600 dyne? s>cm
5
(adults)
Equation:
SVR 1units2 5
MAP 2 CVP
CO
where
MAP = mean arterial pressure (mm Hg)
CVP = central venous (or mean right atrial) pressure (mm Hg)
CO = cardiac output (L/min)
Systemic Vascular Resistance Index
Abbreviation: SVRI
Normal value: 1760–2600 dyne? s>cm
5
>m
2
(children and adults)
10–15 units/m
2
(infants)
15–30 units/m
2
(children and adolescents)
Equation:
SVRI 1units2 5
MPA 2 CVP
CI
84096_CH03_Chatburn.indd 88 6/16/10 6:37:51 AM
Hemodynamics  89
where
MAP = mean arterial pressure (mm Hg)
CVP = central venous (or mean right atrial) pressure (mm Hg)
CI = cardiac index (L/min/m
2
)
Pulmonary Vascular Resistance
Abbreviation: PVR
Normal value: ,160 dyne? s>cm
5
, ,2 units (adults)
Equation:
PVR 1units2 5
MPAP 2 PAOP
CO
where
MPAP = mean pulmonary artery pressure (mm Hg)
PAOP = pulmonary artery occlusion pressure or mean left atrial pressure
(mm Hg)
CO = cardiac output (L/min)
Pulmonary Vascular Resistance Index
Abbreviation: PVRI
Normal value: 45–225 dyne? s>cm
5
>m
2
(children and adults)
8–10 unit/m
2
(newborn)
3 unit/m
2
(infants)
Equation:
PVR 1units2 5
MPAP 2 PAOP
CI
where
MPAP = mean pulmonary artery pressure (mm Hg)
PAOP = pulmonary artery occlussion pressure or mean left atrial
pressure (mm Hg)
CI = cardiac index (L/min/m
2
)
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90  CHAPTER 3 Physiologic Monitoring
Coronary Perfusion Pressure
For mean aortic diastolic pressures between 40 and 80 mm Hg, coronary cir
culation is nearly a linear function of perfusion pressure at the coronary ostia.
Coronary artery collapse occurs at approximately 40 mm Hg. Therefore,
coronary artery perfusion pressure should be maintained at 60 to 80 mm Hg.
Equation:
Coronary perfusion pressure = arterial diastolic pressure – LVEDP
where
LVEDP = left ventricular enddiastolic pressure (mm Hg) and
LVEDP < pulmonary artery occlusion pressure
Cerebral Perfusion Pressure
Abbreviation: CPP
Units: mm Hg
Normal value: 70–110
Equation:
CPP = MAP 2 ICP
where
MAP = mean arterial pressure (mm Hg)
ICP = intracranial pressure (mm Hg)
Stroke Work
The product of the amount of blood ejected from a ventricle multiplied by
the average pressure generated during that heartbeat. It is a parameter used in
evaluating the pumping function of the heart.
Left Ventricular Stroke Work Index
Abbreviation: LVSWI
Units: g? m>m
2
Normal value: 42–64 (children and adults)
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Hemodynamics  91
Equation:
LVSWI = SI 3 (MAP 2 PAOP) 3 0.0136 < SI 3 MAP 3 0.0136
where
SI = stroke index (mL/m
2
)
MAP = mean arterial pressure (mm Hg)
PAOP = pulmonary artery occlusion pressure (mm Hg)
Left Cardiac Work Index
Abbreviation: LCWI
Units: kg ? m/m
2
/min
Normal value: 2.8–4.3 (children and adults)
Equation:
LCWI = CI 3 (MAP 2 PAOP) 3 0.0136 < CI 3 MAP 3 0.0136
where
CI = cardiac index (L/min/m
2
)
MAP = mean arterial pressure (mm Hg)
PAOP = pulmonary artery occlusion pressure (mm Hg)
Right Ventricular Stroke Work Index
Abbreviation: RVSWI
Units: g ? m/m
2
Normal units: 3.8–7.6 (children and adults)
Equation:
RVSWI = SI 3 (MPAP 2 CVP) 3 0.0136 < SI 3 MPAP 3 0.0136
where
SI = stroke index (mL/m
2
)
MPAP = mean pulmonary artery pressure (mm Hg)
CVP = central venous pressure (mm Hg)
84096_CH03_Chatburn.indd 91 6/16/10 6:37:52 AM
92  CHAPTER 3 Physiologic Monitoring
Right Cardiac Work Index
Abbreviation: RCWI
Unit: kg ? m/m
2
/min
Normal value: 0.4–0.6 (children and adults)
Equation:
RCWI = CI 3 (MPAP 2 CVP) 3 0.0136 < CI 3 MPAP 3 0.0136,
where
CI = cardiac index (L/min/m
2
)
MPAP = mean pulmonary artery pressure (mm Hg)
CVP = central venous pressure (mm Hg)
Oxygen Availability (Delivery)
Oxygen availability (sometimes called oxygen delivery) is the total amount
of oxygen potentially available for tissue consumption per unit time.
Abbreviation: O
2
AV, DO
2
, Q
#
O
2
DO
2
I (indexed to BSA)
Unit: mL/min/m
2
(STPD) for DO
2
I, mL/min for DO
2
Normal value: DO
2
5 950–1150 mL/min
DO
2
I 5 520–720 mL/min/m
2
Equations:
DO
2
5 CaO
2
3 CO 3 10
DO
2
I 5 CaO
2
3 CI 3 10
where
Cao
2
= arterial oxygen content (mL/dL)
CI = cardiac index (L/min/m
2
)
CO = cardiac output (L/min)
Note: Brain hypoxia is probable when O
2
AV drops below 450 mL/min/m
2
.
Oxygen Consumption
The amount of oxygen extracted from the blood by the tissues. Oxygen con
sumption may be limited by the oxygen availability or by tissue extraction
(e.g., as in cyanide poisoning). See Tables 3–11 and 3–12.
Abbreviation: V
#
O
2
and V
#
O
2
I (indexed to BSA)
Units: mL/min/m
2
(STPD) for V
#
O
2
I, mL/min for V
#
O
2
Normal value: V
#
O
2
I 5100–180 (children and adults)
V
#
O
2
5 200–250
84096_CH03_Chatburn.indd 92 6/16/10 6:37:53 AM
Hemodynamics  93
Equations:
V
#
O
2
5 1CaO
2
2 CVO
2
2 3 CO
4
3 10
V
#
O
2
5 1CaO
2
2 CVO
2
2 3 CI 3 10
where
Cao
2
= arterial oxygen content (mL/dL)
CVO
2
= mixed venous oxygen content (mL/dL)
Prediction Equations:
Males:
V
#
O
2
= 138.1 2 11.49 3 ln (age) + 0.378 3 (heart rate)
Females:
V
#
O
2
= 138.1 2 17.04 3 ln (age) + 0.378 3 (heart rate)
Table 3–11 Oxygen Consumption (mL/min/m
2
) as a Function of Age and Heart Rate for
Males
Heart Rate (bpm)
Age (yr) 50 60 70 80 90 100 110 120 130 140 150
3 156 159 163 167 171 175 178 182
4 149 152 156 160 164 168 171 175 179
6 140 144 148 152 155 159 163 167 170 174
8 137 141 144 148 152 156 160 163 167 171
10 131 134 138 142 146 149 153 157 161 165 168
12 128 132 136 140 144 147 151 155 159 162 166
14 127 130 134 138 142 14 149 153 157 161 164
16 125 129 133 136 140 144 148 152 155 159 163
18 124 128 131 135 139 143 146 150 154 158 162
20 123 126 130 134 138 141 145 149 153 157 160
25 120 124 128 131 135 139 143 146 150 154 158
30 118 122 125 129 133 137 141 144 148 152 156
35 116 120 124 127 131 135 139 143 146 150
40 115 118 122 126 130 134 137 141 145 149
84096_CH03_Chatburn.indd 93 6/16/10 6:37:53 AM
94  CHAPTER 3 Physiologic Monitoring
where
heart rate is in beats per minute
ln represents the natural logarithm (i.e., log
e
)
Oxygen Extraction Ratio
A ratio of the oxygen consumption to the oxygen availability and an indica
tor of the body’s metabolic level (for a given cardiac output). Conversely,
given a stable level of hemoglobin, arterial saturation, and oxygen consump
tion, an increasing oxygen extraction ratio indicated a fall in cardiac output.
Abbreviation: O
2
ER
Units: %
Normal value: 22–30 (children and adults)
Table 3–12 Oxygen Consumption (mL/min/m
2
) as a Function of Age and Heart Rate for
Females
Heart Rate (bpm)
Age (yr) 50 60 70 80 90 100 110 120 130 140 150
150 153 157 161 165 169 172 176
141 145 148 152 156 160 164 167 171
130 134 138 142 145 149 153 157 160 164
125 129 133 137 140 144 148 152 156 159
10 118 122 125 129 133 137 140 144 148 152 156
12 115 118 122 126 130 134 137 141 145 149 152
14 112 116 120 123 127 131 135 138 142 146 150
16 110 114 117 121 125 129 132 136 140 144 148
18 108 112 115 119 123 127 130 134 138 142 146
20 106 110 114 117 121 125 129 132 136 140 144
25 102 106 110 113 117 121 125 129 132 136 140
30 99 103 107 110 114 118 122 126 129 133 137
35 96 100 104 108 112 115 119 123 127 130
40 94 98 102 105 109 113 117 121 124 128
84096_CH03_Chatburn.indd 94 6/16/10 6:37:53 AM
Hemodynamics  95
Equation:
O
2
ER 5
1CaO
2
2 CVO
2
2
CaO
2
where
Cao
2
= arterial oxygen content (mL/dL)
CVO
2
= mixed venous oxygen content (mL/dL)
Oxygen Extraction Index
Abbreviation: O
2
EI
Units: %
Normal value: 22–25%
Equation:
O
2
EI 5
1SaO
2
2 SVO
2
2
SaO
2
where
SaO
2
= Oxygen saturation of arteral blood
SVO
2
= Oxygen saturation of mixed venous blood
84096_CH03_Chatburn.indd 95 6/16/10 6:37:53 AM
Intentional Blank 96
84096_CH03_Chatburn.indd 96 6/16/10 6:37:53 AM
CHAPTER
4
CHAPTER
4
Gas Therapy
84096_CH04_Chatburn.indd 97 6/18/10 11:00:51 AM
98  CHAPTER 4 Gas Therapy
For the respiratory care practitioner to provide gas therapy effectively, it
is necessary to understand the physics of gases. This chapter will describe
the relationships among pressure, temperature, mass, and volume for most
medical gases. This chapter will also describe the packaging, distribution,
and conversion equations that permit the practitioner to use these gases effec
tively.
The General Gas law ■
The behavior of an ideal gas is governed by the interdependent relationships
of four thermodynamic variables: mass, pressure, volume, and absolute tem
perature. The equation relating these variables is called the ideal gas law and
is written as
PV 5 nRT
where
P 5 absolute pressure of dry gas in atmospheres (atm)
V 5 volume in liters (L)
n 5 moles of gas
R 5 the universal gas constant: (0.0821 L ? atm/mole ? K)
T 5 absolute temperature in degrees Kelvin (K)
Since water vapor in a saturated mixture does not act like an ideal gas, the
preceding equation is applied to the dry gas portion of the mixture. If a gas
is saturated with water vapor, at a given temperature its dry gas pressure is
obtained by subtracting the water vapor at that temperature.
In situations where mass (i.e., number of moles) remains constant, the
general gas law is often simplified to PV/T 5 k, where k is a constant.
Furthermore, the general gas law is most often utilized to correct for the vol
ume change when pressure and temperature are changed. We would use the
combined gas law form:
P
1
V
1
T
1
5
P
2
V
2
T
2
A common and useful application of the combined general gas law is con
verting gas volumes from room temperature (ATPS) to body conditions
(BTPS).
84096_CH04_Chatburn.indd 98 6/18/10 11:00:51 AM
Special Gas Laws  99
Problem:
Correct a measured vital capacity of 4.8 L to BTPS given that the patient’s body
temperature is normal and the pulmonary function laboratory is at sea level with a
room temperature of 258C.
Solution:
Condition 1 5 ATPS
P
1
5 PB 2 PH
2
O
5 760 2 23.8 1at 258C2
5 736.2 mm Hg
V
1
5 4.8 L
T
1
5 258C 1 273 5 298 K
Condition 2 5 BTPS
P
2
5 760 2 47 1at 378C2
5 713 mm Hg
V
2
5 unknown value
T
2
5 378C 1 273 5 310 K
We derive the formula for converting gas volume from ATPS to BTPS by solving the
combined gas law for V
2
,
P
1
V
1
T
1
5
P
2
V
2
T
2
V
2
5
P
1
V
1
T
2
T
1
P
2
and substituting the known values:
V
2
5
732.2 3 4.8 3 310
298 3 713
5 5.2 L
special Gas laws ■
Boyle’s Law
If temperature and mass remain constant, the volume of a gas varies inverse
ly with the pressure applied to that gas. Symbolically,
V 5
k
P
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100  CHAPTER 4 Gas Therapy
or, equivalently,
P
1
V
1
5 P
2
V
2
where
k is a constant
Problem:
Consider a syringe filled with a certain amount of dry gas. If the outlet is blocked
while the plunger is depressed, the pressure of the gas inside the syringe will rise as
its volume decreases (we assume that there are no leaks and that the temperature
change of the gas is negligible). If the gauge pressure of the gas is 30 cm H
2
O when
the volume of the gas is 40 mL, what will the pressure be when the gas is com
pressed to 35 mL?
Solution:
Condition 1:
P
1
(absolute) 5 gauge pressure + atmospheric pressure
30 cm H
2
O 5 22 mm Hg
P
1
5 22 + 760 5 782 mm Hg
V
1
5 40 mL
Condition 2:
P
2
5 unknown value
V
2
5 35 mL
Solving Boyle’s law for the unknown variable gives
P
1
V
1
5 P
2
V
2
P
2
5
P
1
V
1
V
2
5 782 3
40
35
5 894 mm Hg
P
2
(gauge) 5 (894 2 760) 3 1.36
5 182 cm H
2
O
Another example of Boyle’s law is the effect of altitude changes on the vol
ume of trapped gas (e.g., a pneumothorax), as shown in Table 4–1.
84096_CH04_Chatburn.indd 100 6/18/10 11:00:52 AM
Special Gas Laws  101
Table 4–1 The Effect of Altitude on Trapped Gas
Altitude
(ft) (m) Expansion
10,000 3,048 150%
18,000 5,486 200%
27,000 8,230 300%
33,000 10,058 400%
38,500 11,735 500%
Charles’s Law
If pressure and mass remain constant, the volume of a gas varies directly
with the temperature of that gas. The equations are
V 5 kT
or, equivalently,
V
1
T
1
5
V
2
T
2
where
k is a constant
Problem:
Suppose a certain quantity of helium occupies a volume of 6.0 L at a room tempera
ture of 228C. If the same mass of helium were heated to 378C, what would its new
volume be?
Solution:
Condition 1:
V
1
5 6.0 L
T
1
5 228C + 273 5 295 K
Condition 2:
V
2
5 unknown value
T
2
5 378C + 273 5 310 K
Solving the above equation for the unknown quantity, we obtain
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102  CHAPTER 4 Gas Therapy
V
1
T
1
5
V
2
T
2
V
2
5
V
1
T
2
T
1
Substituting the known quantities gives
V
2
5 6.0 3
310
295
5 6.3 L
GayLussac’s Law
If volume and mass remain constant, the pressure of a gas varies directly
with the temperature of that gas. Thus,
P 5 kT
or
P
1
T
1
5
P
2
T
2
where
k is a constant
Problem:
A common example occurs at those institutions in the northern latitude that store
their gas cylinders outside. If an H cylinder of oxygen was filled to 2200 psi at room
temperature (228C), what is its pressure at 2108C?
Solution:
Condition 1:
P
1
(absolute) 5 gauge pressure + atmospheric pressure
P
1
5 2200 psi + 14.7 < 2215 psi
T
1
5 228C + 273 5 295 K
Condition 2:
P
2
5 unknown value
T
1
5 2108C + 273 5 263 K
Using the preceding equation, we solve for the unknown pressure:
84096_CH04_Chatburn.indd 102 6/18/10 11:00:52 AM
Special Gas Laws  103
P
1
T
1
5
P
2
T
2
P
2
5
P
1
T
2
T
1
Substituting the known values gives
P
2
5 2215 3 263/295
5 1975 psi
P
2
(gauge) 5 1975 2 15
5 1960 psi/gauge pressure
Avogadro’s Law
If pressure and temperature remain constant, the mass of a gas varies directly
with the volume of that gas:
n 5 kV
or, equivalently,
n
1
V
1
5
n
2
V
2
where
k is a constant
n is the number of moles of the gas
From these equations it follows that equal volumes of gases at the same pres
sure and temperature have the same number of moles. Furthermore, one gram
molecular weight of a gas (i.e., the atomic weight of the molecule expressed
in grams) occupies 22.4 L at STPD and contains 6.02 × 10
23
molecules.
Avogadro’s law provides the basis for the derivation of the density (mass per
unit volume) of a gas. For example, the density of oxygen (ro
2
) is its gram
molecular weight (gmw) divided by 22.4 L:
1 gmw O
2
5 16 × 2 × 1 g 5 32 g
ro
2
5 32/22.4 5 1.43 g/L at STPD.
84096_CH04_Chatburn.indd 103 6/18/10 11:00:52 AM
104  CHAPTER 4 Gas Therapy
Specific gravity is a ratio of densities. Usually, gas densities are compared
to air ( rair 5 1.28 g/L at STPD). Calculation of specific gravity for oxygen
reveals that it is heavier than air:
specific gravity of O
2
5
1.43 g>L
1.28 g>L
or 5 1.12
It is this property of oxygen that causes the “layering” of oxygen in tents,
making the Fio
2
at the bottom of the canopy higher than at the top.
Dalton’s Law of Partial Pressures
The total pressure of a gas mixture is equal to the sum of the partial pressures
of the constituent gases. The partial pressure of each gas is the pressure it
would exert if it occupied the entire volume alone:
Ptotal 5 P
1
+ P
2
+ P
3
+
. . .
+ P
n
The partial pressure of each gas is proportional to its molar concentration in
the mixture:
Pg 5 Fg 3 Ptotal
where
Pg is the partial pressure of the gas
Fg is the fractional concentration of the gas in the mixture
Dalton’s law is important because it allows us to calculate the partial pres
sures of various inhaled gases. The physiologic effects of each component
of inhaled air depend on the partial pressure of the component in the lungs
rather than on the total pressure.
As a rough approximation, the partial pressure (in kPa) is close to the con
centration (in %) at normal barometric pressure. Partial pressure in mm
Hg can be approximated by multiplying the concentration (in %) by 7. For
example, the Po
2
of air is approximately 21 3 7 5 147 mm Hg.
Poiseuille’s Law
Poiseuille’s law describes the mechanics of laminar fluid flow through a
tube.
V
#
5
Ppr
4
8hl
84096_CH04_Chatburn.indd 104 6/18/10 11:00:52 AM
Special Gas Laws  105
where
V
#
5 flow in cm
3
/s
P 5 pressure difference across the ends of the tube (dyne/cm
2
)
p 5 3.1416 . . .
r 5 radius of tube (cm)
l 5 length of tube (cm)
h 5 viscosity in poise (dyne ? s/cm
2
)
The preceding equation indicates that the pressure difference is directly pro
portional to the gas flow rate. Thus, for any flow rate, the pressure difference
divided by the flow rate equals a constant. This constant is called resistance
(R) and is defined as
R 5
8hl
pr
4
5
P
V
#
The clinical significance of this definition centers around the importance
of tube radius. For instance, if the radius of an airway is halved, the airway
resistance in that section increases 16fold. Bronchospasm and mucous
obstruction are two frequently encountered clinical conditions that reduce
airway caliber (increasing airway resistance), resulting in a rise in proximal
airway pressure during volume control ventilation or acute hypoventilation
during pressure control ventilation.
Another important point about this definition is that the only property of
the gas that influences resistance during laminar flow is viscosity. This
is in contrast to turbulent flow in which resistance is proportional to gas
density. Therefore, under conditions of laminar flow, the clinical use of a
lowdensity, highviscosity gas (e.g., helium) will do nothing to improve gas
flow. However, if excessive airway resistance is caused by turbulence (as in
croup or other forms of airway obstruction), density, not viscosity, becomes
important.
Reynold’s Number
The factors that determine whether flow in a tube will be laminar or turbulent
are related in the equation that defines a dimensionless quantity called the
Reynold’s number:
NR 5
inertial force
viscous force
5
rv
2
h1v>2r2
5
r2rv
h
84096_CH04_Chatburn.indd 105 6/18/10 11:00:52 AM
106  CHAPTER 4 Gas Therapy
where
v 5 average linear velocity of the gas (cm/s)
r 5 radius of tube (cm)
r 5 density of gas (g/cm
3
)
h 5 viscosity in poise (dyne ? s/cm
2
)
In straight, smooth tubes, turbulence for most fluids is probable when the
Reynold’s number exceeds 2000. Once flow becomes turbulent, the pressure
difference required to produce a given gas flow rate through a given passage
is proportional to gas density and the square of the gas flow rate but is inde
pendent of viscosity.
Bernoulli Theorem
For an incompressible fluid in laminar flow (assuming that there are no ener
gy losses from friction), Bernoulli’s equation states that the energy densities
at any two points in the system are equal:
PE
1
5 P
1
+ KE
1
5 PE
2
+ P
2
+ KE
2
where
PE 5 potential energy per unit volume or height 3 density 3 gravita
tional acceleration
P 5 pressure of the gas measured perpendicular to flow
KE 5 kinetic energy per unit volume or 1/2 density 3 velocity squared
Consider a fluid that flows from a relatively wide section of tubing (subscript
1 in the above equation) to a relatively narrow section (subscript 2). Since
the crosssectional area in the narrow section is smaller, the velocity of the
fluid must increase to keep the flow rate the same. As a result, the kinetic
energy density (KE
2
) increases. Assuming that the potential energy density
stays the same, the pressure (P
2
) at this point must decrease so that the right
side of the equation remains equal to the left. Stated simply, as the forward
velocity of the fluid increases, its radial pressure decreases. This is often
called the Bernoulli effect.
Henry’s Law (Law of Solubility)
When a liquid and gas are in equilibrium, the amount of gas in solution
is directly proportional to the partial pressure of the gas if temperature is
84096_CH04_Chatburn.indd 106 6/18/10 11:00:52 AM
Special Gas Laws  107
constant. Expressed mathematically this is
C 5 0.132aP
where
C 5 gas concentration in vol% (mL gas/dL liquid)
a 5 the Bunsen solubility coefficient of the gas (mL gas STPD/mL
solvent) (see Table 4–2)
P 5 gas partial pressure (mm Hg)
0.132 5 a constant equal to 100/760 used to express C in vol%
Table 4–2 Bunsen Solubility Coefficients (mL STPD/mL Solvent)
*
Gas Plasma Blood
**
He 0.0154 0.0149
N
2
0.0117 0.0130
O
2
0.0209 0.0240
CO
2
0.5100 0.4700
*
Gas partial pressure 5 760 mm Hg and temperature 5 378C.
**
Hematocrit 5 0.45.
Graham’s Law (Law of Diffusion)
Graham’s law states that the diffusion of a gas is inversely proportional to
the square root of its molecular weight. For example, in comparing the rela
tive rates of diffusion of carbon dioxide and oxygen, we get
DCO
2
DO
2
5
2gmw O
2
2gmw CO
2
5
232
244
5
5.6
6.6
where
Dco
2
5 diffusion coefficient for carbon dioxide
Do
2
5 diffusion coefficient for oxygen
gmw 5 gram molecular weight
From this we see that carbon dioxide diffuses only 0.85 times as fast as oxy
gen in the gaseous state owing to carbon dioxide’s greater molecular weight.
84096_CH04_Chatburn.indd 107 6/18/10 11:00:52 AM
108  CHAPTER 4 Gas Therapy
Fick’s Law of Diffusion
The factors controlling the rate of diffusion of a gas into or out of a liquid are
expressed in the equation
V
#
GAS r 5
DP 3 A 3 S
d 3 2gmw
where
V
#
GAS 5 diffused gas flow
DP 5 pressure gradient across the gas–liquid interface
A 5 crosssectional area
S 5 solubility of gas
d 5 distance for diffusion
gmw 5 gram molecular weight of the gas
In comparing the rates of diffusion of carbon dioxide and oxygen through an
aqueous medium, it should be noted that for the same concentration gradient,
carbon dioxide diffuses more slowly than oxygen. However, because of its
25 times greater solubility, carbon dioxide diffuses 20 times faster than oxy
gen for the same tension gradient.
Law of Laplace (for a Sphere)
The pressure difference between the inside and outside of a sphere is depen
dent on the surface tension of the air–liquid interface and the radius of the
bubble. For a sphere with one air–liquid interface (e.g., an alveolus or a gas
bubble in a liquid), the equation is
Ptrans 5
2T
r
where
Ptrans 5 transmural pressure differences (dyne/cm
2
)
T 5 surface tension (dyne/cm)
r 5 radius of sphere (cm)
For a sphere with two air–liquid interfaces (e.g., a sphere of gas enclosed in a
thin film of liquid such as a soap bubble), the equation becomes
PTRANS 5
4T
r
84096_CH04_Chatburn.indd 108 6/18/10 11:00:53 AM
Special Gas Laws  109
In either case, the Laplace equation indicates that the smaller the radius of
the sphere, the higher its transmural pressure difference. Thus, it would seem
that a small alveolus would have the natural tendency to empty its gas into a
larger one and collapse. This tendency is counteracted by the presence of sur
factant on the inner surface of the alveolus. Surfactant decreases the surface
tension inside the alveolus in proportion to the ratio of surfactant to alveolar
surface area. As an alveolus becomes smaller, the amount of surfactant per
unit of surface area increases. This causes the surface tension to decrease to a
greater extent than the corresponding reduction of radius so that the pressure
(5 2T/r) decreases. Thus, small alveoli in communication with large alveoli
are able to equilibrate to the same pressure without collapsing.
Absolute Humidity
Absolute humidity is the water vapor density expressed in grams per cubic
meter (or milligrams per liter) of air. It can be estimated using the following
equation (derived from the ideal gas equation):
AH 5
287.7 3 RH 3 PSAT
t 1 273
where
AH 5 absolute humidity (mg/L or g/m
3
)
RH 5 relative humidity expressed as a decimal
Psat 5 the partial pressure of saturated water vapor (mm Hg) at the
given temperature, t
t 5 temperature (8C)
Relative Humidity
The ratio of the actual amount of water vapor in a gas (absolute humidity) at
a given temperature to the amount of water vapor the gas could hold if satu
rated at that temperature (capacity) is the relative humidity. Mathematically,
it is
relative humidity 1%2 5
absolute humidity
capacity
3 100
relative humidity 1%2 5
measured water vapor pressure
saturated water vapor pressure
3 100
84096_CH04_Chatburn.indd 109 6/18/10 11:00:53 AM
110  CHAPTER 4 Gas Therapy
Goff–Gratch Equation
Saturated water vapor pressure can be estimated from the temperature of the
gas using the following adaptation of the Goff–Gratch equation (in computer
or calculator notation):
Psat 5 K * (10ˆ(((–7.90298) * (373.16/t 2 1))
+ (5.02808 * LOG(373.16/t))
2 (1.3816 * 10ˆ(27) * (10ˆ(11.334 * (1 2 t/373.16)) 2 1))
+ (8.132 * 10ˆ(23) * (10ˆ(23.49149 * (373.16/t 2 1)) 2 1))))
where t is the temperature of the gas in degrees kelvin, LOG is logarithm
(base 10), and K is a constant determined by the desired units for Psat. The
symbol + stands for multiplication, / stands for division, and ˆ represents
exponentiation (i.e., 10ˆ2 5 100). Table 4–3 gives the values of K for vari
ous units of pressure.
Table 4–3 Goff–Gratch Equation Constants for Various Units of Pressure
Desired Unit K
atmosphere (atm) 1
pounds/in.
2
(psi) 14.696
inches of mercury (in. Hg) 29.9213
millimeters of mercury (mm Hg) 760
centimeters of water (cm H
2
O) 1033.26
millibars (mb) 1013.25
kilopascals (kPa) 101.3
Antoine Equation
The saturated vapor pressure of water and a variety of anesthetic gases can
be estimated using the Antoine equation:
PSAT 5 antilogaA 2
B
t 1 C
b
where
Psat 5 units of pressure desired
antilog 5 the antilogarithm (base 10) of the expression in parentheses
84096_CH04_Chatburn.indd 110 6/18/10 11:00:53 AM
Special Gas Laws  111
A, B, and C 5 constants whose values depend on the chemical composi
tion of the vapor. Table 4–4 gives values of A, B, and C for water and
varieties of anesthetic gases.
t 5 temperature (8C)
Table 4–4 Antoine Equation Data
Substance A
(kPA)
(mm Hg)
B C Temperature
Range
of Data (8C)
Maximum
Deviation
from Data
Water 7.16728 1716.984 232.538 25–135 1%
8.04343
Nitrous
oxide
6.70184 912.8988 285.309 240–36 1%
7.57799
Halothane 5.89184 1043.697 218.262 251–55 3%
6.76799
Isoflurane 4.82163 536.4589 140.991 25–49 1%
5.69778
Enflurane 6.11225 1107.839 213.063 17–56 0.3%
6.98840
Table 4–5 gives values for water vapor pressure, content, and saturation for
temperatures, commonly encountered in health care.
Table 4–5 Water Vapor Pressure, Content, and Percent Saturation
Temperature
(8C)
Vapor Pressure
(mm Hg)
Water Content
(mg/L)
% Saturation at
378C
20 17.54 17.30 39
22 19.88 19.42 44
24 22.38 21.78 50
26 25.21 24.36 55
28 28.35 27.22 62
30 31.82 30.35 69
32 35.66 33.76 77
34 39.90 37.56 86
(continued)
84096_CH04_Chatburn.indd 111 6/18/10 11:00:53 AM
112  CHAPTER 4 Gas Therapy
Table 4–5 Water Vapor Pressure, Content, and Percent Saturation (continued)
Temperature
(8C)
Vapor Pressure
(mm Hg)
Water Content
(mg/L)
% Saturation at
378C
36 44.56 41.70 95
37 47.07 43.90 100
38 49.69 46.19 —
40 55.32 51.10 —
42 61.50 56.50 —
Figure 4–1 Water vapor pressure and content as a function of temperature (from the
Antoine equation).
kPa mm Hg mg/L
8 60
55
50
40
30
20
45
35
25
15
5
10
0
7
6
5
4
3
2
1
0
0 5 10 15 20 25 30 35 40
Temperature (°C)
W
a
t
e
r
V
a
p
o
r
P
r
e
s
s
u
r
e
W
a
t
e
r
V
a
p
o
r
C
o
n
t
e
n
t
50
40
30
20
10
0
100
80
60
40
20
% Saturation
84096_CH04_Chatburn.indd 112 6/18/10 11:00:54 AM
Oxygen Administration  113
OxyGen adminisTraTiOn ■
Blender or Entrainment System Equations
The following equations relate the variables of oxygen, flow, airflow, total
flow, and fraction of inspired oxygen (Fio
2
) when blenders or entrainment
systems are used.
FIO
2
5
O
2
flow 1 10.21 3 airflow2
total flow
5 0.21 1
10.79 3 O
2
flow2
total flow
O
2
flow 5
total flow 3 1FIO
2
2 0.212
0.79
airflow 5 total flow 2 O
2
flow
total flow 5
O
2
flow 3 0.79
FIO
2
2 0.21
airflow
O
2
flow
5
1.0 2 FIO
2
FIO
2
2 0.21
These equations were derived from the general equations
(Fo
2
)(total flow) 5 (Fao
2
)(flow A) + (Fbo
2
)(flow B)
and
total flow 5 flow A + flow B
where
Fo
2
5 final fraction of oxygen in mixture
FxO
2
5 fractional concentration of oxygen in the individual flows
making up the mixture
This equation simply states that the total flow of oxygen in the mixture is
equal to the sum of the flows of oxygen in the gases being blended together.
84096_CH04_Chatburn.indd 113 6/18/10 11:00:54 AM
((+ s :?8GK<I+ >XjK_\iXgp
In the home care environment, it is often necessary to blend oxygen into the
gas delivered by a home care ventilator, as these devices usually do not pro
vide control of Fio
2
. If pure oxygen is used, the preceding equations apply.
However, it may be convenient to use an oxygen concentrator. In this case,
the fractional concentration of oxygen delivered by the concentrator (FCo
2
)
must be known. The relationships among Fio
2
total minute ventilation
(V
E, the total flow of gas from the ventilator and the concentrator), concen
trator flow rate (V
C), and the flow of gas from the ventilator (V
AIR equal to
the product of tidal volume and ventilator frequency) may be expressed as
follows.
FIO
2
V
C FCO
2
V
AIR 0.21
V
E
V
E V
C
FCO
2
0.21
FIO
2
0.21
V
AIR V
C
FCO
2
FIO
2
FIO
2
0.21
V
AIR V
E V
E
FIO
2
0.21
FCO
2
0.21
V
C V
E
FIO
2
0.21
FCO
2
0.21
If the FCo
2
drifts from its expected value due to concentrator malfunction,
the resultant effect on Fio
2
may be estimated using the equation:
act FIO
2
expt FIO
2
0.21
expt FCO
2
0.21
act FCO
2
0.21 0.21
where
act actual
expt expected
Derivaticn cf Apprcximate F@F
2
fcr LcwFIcw 0xyçen
System
Fio
2
volume of inspired O
2
÷ tidal volume (Vt)
Oxygen Administration  115
volume of inspired O
2
5 (a) volume of O
2
inspired from anatomic
reservoir
plus
(b) volume of O
2
delivered by cannula during
inspiration
plus
(c) volume of O
2
from inspired room air
Example
normal Vt 5 500 mL
frequency 5 20 breath/min
inspiratory time 5 1 s
expiratory time 5 2 s
period of no expiratory flow 5 25% of expiratory time 5 0.5 s
anatomic reservoir 5 50 mL < 30% of anatomic dead space
nasal cannula flow rate 5 6 L/min (100 mL/s)
Thus,
(a) volume of O
2
inspired from anatomic reservoir 5 100 mL/s 3 0.5 s 5 50 mL
(b) volume of O
2
delivered by cannula during inspiration 5 100 mL/s 3 1.0 s
5 100 mL
(c) volume of O
2
from inspired room air 5 0.20 3 (Vt 2 Vd) 5 0.20 3 (500 2
150) 5 70 mL
Therefore,
volume of inspired O
2
5 50 mL + 100 mL + 70 mL 5 220 mL
and
Fio
2
5 220 mL 4 500 mL 5 0.44
84096_CH04_Chatburn.indd 115 6/18/10 11:00:54 AM
116  CHAPTER 4 Gas Therapy
Table 4–6 LowFlow Oxygen Systems
*
System O
2
Flow Rate (L/min) Approximate Fio
2
Nasal cannula or catheter 1 0.24
2 0.28
3 0.32
4 0.36
5 0.40
6 0.44
Simple oxygen mask 5–10 0.35–0.50
Mask with reservoir bag 8–10 0.60–0.80
*
Normal tidal volume and respiratory rate are assumed.
Data from Wilkins, R. L., Stoller, J. K., Kacmarek, R. M. Egan’s Fundamentals of Respiratory Care. 9th Edition. St.
Louis: Mosby Elsevier; 2009:874.
Figure 4–2 Inspired oxygen concentration as a function of mixed air and oxygen flow
rates (low range of flow).
25 30 40 45 50 55 60
65
70
80
90
75
85
95
35
FIO
2
(%)
Oxygen (L/min)
18
16
14
12
10
8
6
4
2
0 1 2 3 4 5 6 7 8 9 10
1
2
3
4
5
6
7
8
9
10
A
i
r
(
L
/
m
i
n
)
Total Flow
84096_CH04_Chatburn.indd 116 6/18/10 11:00:55 AM
Gas Cylinders  117
Gas cylinders ■
Duration of Cylinders
The first step in calculating the duration of flow from a cylinder of com
pressed gas is to relate the decrease in cylinder volume to the drop in the cyl
inder’s gauge pressure. The factor K, relating gas volume to pressure drop, is
calculated as follows:
K 1L>psi2 5
28.3 1L>ft
3
2 3 volume of gas in full cylinder 1ft
3
2
pressure of full cylinder 1psi2
where
28.3 5 the factor to convert cubic feet to liters
Table 4–7 gives values for the K factors for different gases and cylinder
sizes.
Figure 4–3 Inspired oxygen concentration as a function of mixed air and oxygen flow
rates (high range of flow).
25 30 40 45 50 55 60
65
70
80
90
75
85
95
35
FIO
2
(%)
Oxygen (L/min)
90
80
70
60
50
40
30
20
0 5 10 15 20 25 30 35 40 45 50
5
10
15
20
25
30
35
40
45
50
A
i
r
(
L
/
m
i
n
)
Total Flow
10
84096_CH04_Chatburn.indd 117 6/18/10 11:00:55 AM
118  CHAPTER 4 Gas Therapy
Once the value of K is found for a particular size of cylinder, the duration of
constant flow can be calculated from the gauge pressure using the equation:
duration of flow 1min2 5
K 3 gauge pressure 1psi2
flow rate 1L>min2
Table 4–8 gives approximate number of hours of flow according to cylinder
size.
Helium Therapy
Helium is odorless, tasteless, nonexplosive, and physiologically inert.
Because of its low density, helium has been used in the management of
airway obstruction where turbulent gas flow patterns cause an increase in
airway resistance and increase the work of breathing. Commercially pre
pared cylinders of helium–oxygen mixtures are available in 80%–20% and
70%–30% combinations.
Because the calibration of standard flowmeters (i.e., Thorpe tube) depends on
gas properties, a correction must be applied when helium–oxygen mixtures
are used with flowmeters calibrated for oxygen or air. The calibration factor
of a flowmeter is inversely proportional to the square root of the molecu
lar weight of the gas. Therefore, if a 70%–30% helium–oxygen mixture is
used with an oxygen flowmeter, the measured flow must be multiplied by
2gmw O
2
> 2gmw mixture to obtain the actual flow rate. Thus, to obtain a
desired flow rate of a given mixture with an oxygen flowmeter, the following
equations are used.
80%–20% helium–oxygen mixture:
required flowmeter setting 5
desired flow rate
1.8
70%–30% helium–oxygen mixture:
required flowmeter setting 5
desired flow rate
1.6
84096_CH04_Chatburn.indd 118 6/18/10 11:00:55 AM
Gas Cylinders  119
Gas Therapy Working Tables and Figures
Table 4–7 K Factors (L/psi) to Calculate Duration of Cylinder Flow
Cylinder Size
Gas D E G H and K
O
2
, CO
2
, N
2
, air 0.16 0.28 2.41 3.14
O
2
/CO
2
0.20 0.35 2.94 3.84
He/O
2
0.14 0.23 1.93 2.50
Table 4–8 Approximate Number of Hours of Flow
Flow Rate
(L/min)
Cylinder Type
Full 3/4 Full 1/2 Full 1/4 Full
E H E H E H E H
2 5.1 56 3.8 42 2.5 28 1.3 14
4 2. 28 1.8 21 1.2 14 0.6 7
6 1.7 18.5 1.3 13.7 0.9 9.2 0.4 4.5
8 1.2 14 0.9 10.5 0.6 7 0.3 3.5
10 1.0 11 0.7 8.2 0.5 5.5 0.2 2.7
12 0.8 9.2 0.6 6.7 0.4 4.5 0.2 2.2
15 0.6 7.2 0.4 5.5 0.3 3.5 0.1 1.7
Table 4–9 Medical Gas Cylinder Color Codes*
Gas Symbol United States International
Carbon dioxide CO
2
Gray Gray
Cyclopropane C
3
H
6
Orange Orange
Ethylene C
2
H
6
Red Violet
Helium He Brown Brown
Nitrous oxide N
2
O Blue Blue
Oxygen O
2
Green White
Oxygen–carbon dioxide Gray + green Gray + white
Oxygenhelium Brown + green Brown + white
Air Yellow + silver White + black
*
Note: Color codes are accurate for E cylinders only.
84096_CH04_Chatburn.indd 119 6/18/10 11:00:55 AM
120  CHAPTER 4 Gas Therapy
Table 4–10 Medical Gas Cylinder Dimensions
Diameter Height Weight
Size (in.) (cm) (in.) (cm) (lb) (kg)
A 3 7.6 10 25.4 2.5 5.5
B 3.5 8.9 16 40.6 5.25 11.6
D 4.25 10.8 20 50.8 10.25 22.6
E 4.5 11.4 30 76.2 15 33
M 7 17.8 47 119.4 66 145.2
G 8.5 21.6 55 139.7 98 215.6
H&K 9 22.9 55 139.7 100 220
Table 4–11 Medical Gas Cylinder Specifications
Gas
Pressure
(psi)
Cylinder Size
D E G H & K
Oxygen 1800–2400 ft
3
12.6 22 186 244
L 356 622 5260 6900
Carbon dioxide 840 ft
3
33 56 425
L 934 1585 12,000
Helium 1650–2000 ft
3
10.6 17 146
L 300 480 4130
Nitrous oxide 745 ft
3
34.5 57 485 577
L 975 1610 13,750 15,800
Cyclopropane 80 ft
3
30
L 848
Ethylene 1250 ft
3
26.6 44 372
L 752 1245 10,500
Oxygen–carbon
dioxide mix
1500–2200 ft
3
12.6 22 186
L 356 622 5620
Oxygen–helium
mix
1650–2000 ft
3
11 18 150
L 310 510 4250
84096_CH04_Chatburn.indd 120 6/18/10 11:00:56 AM
Gas Cylinders  121
Table 4–12 Pin Index and CGA Standards
Gas Pin Position CGA Con. No.
*
Oxygen 2–5 870
Carbon dioxide–oxygen (CO
2
not over 7%) 2–6 880
Helium–oxygen (He not over 80%) 2–4 890
Ethylene 1–3 900
Nitrous oxide 3–5 910
Cyclopropane 3–6 920
Helium 4–6 930
Helium–oxygen (He not over 80%)
Carbon dioxide 1–6 940
Carbon dioxide–oxygen (CO
2
over 7%) (mix
tures other than those shown above; for lab
use only)
No CGA
standard
*
CGA Con. 5 Compressed Gas Association connection.
Table 4–13 New Standard Threaded Valve Outlet Connections for Medical Gases
Gas Outlet Thread CGA
Connection
Oxygen 0.903”14NGORHEXT. 540
Carbon dioxide
Carbon dioxide–oxygen (CO
2
over 7%) 0.825”14NGORHEXT.
(flat nipple)
320
Carbon dioxide–oxygen
(CO
2
not over 7%)
Helium–oxygen (He not over 80%) 0.745”14NGORHEXT. 280
Helium
Helium–oxygen (He over 80%) 0.965”14NGORHINT. 580
Nitrous oxide 0.825”14NGORHEXT.
(small round nipple)
1320
Ethylene 0.825”14NGOLHEXT.
(round nipple)
350
Cyclopropane 0.885”14NGOLHINT. 510
Special mixtures (mixtures other than
those shown above)
0.825”14NGORHEXT.
(flat nipple)
320
84096_CH04_Chatburn.indd 121 6/18/10 11:00:56 AM
122  CHAPTER 4 Gas Therapy
Figure 4–4 Pplt index, CGA standard. (See Table 4–12.)
1
2
3
6
5
4
Figure 4–5 Schematic illustration of components of a representative diameter index
safety system (DISS) connection. The two shoulders of the nipple allow the nipple to
unite only with a body having corresponding borings.
Body Nipple and hex nut
Bore 1
Bore 2 Shoulder 1
Shoulder 2
84096_CH04_Chatburn.indd 122 6/18/10 11:00:58 AM
Gas Cylinders  123
Table 4–14 Gas Volume Correction Equations*
To Convert From To Multiply By
ATPS (ambient temperature and
pressure, saturated with water vapor)
STPD PB 2 PH
2
O
760
3
273
273 1 T
BTPS PB 2 PH
2
O
PB 2 47
3
310
273 1 T
ATPD PB 2 PH
2
O
PB
ATPD (ambient temperature and
pressure, dry)
STPD PB
760
3
273
273 1 T
BTPS PB
PB 2 47
3
310
273 1 T
ATPS PB
PB 2 PH
2
O
BTPS (body temperature and ambient
pressure, saturated with water vapor
at body temperature)
STPD PB 2 47
760
3
273
310
ATPS PB 2 47
PB 2 PH
2
O
3
273 1 T
310
ATPD PB 2 47
PB
3
273 1 T
310
STPD (standard temperature and
pressure, dry)
BTPS 760
PB 2 47
3
310
273
ATPS 760
PB 2 PH
2
O
3
273 1 T
273
ATPD 760
PB
3
273 1 T
273
*Based on ambient temperature (T) in 8C, barometric pressure (Pb) in mm Hg, and the saturating pressure of
water (Ph
2
o) in mm Hg at ambient temperature.
84096_CH04_Chatburn.indd 123 6/18/10 11:00:59 AM
124  CHAPTER 4 Gas Therapy
Table 4–15 Conversion Factors to Correct Volume (ATPS) to Volume (BTPS)*
Gas Temperature (8C) Factor
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
*Volume (BTPS) 5 volume (ATPS) 3 conversion factor.
Note: These factors have been calculated for a barometric pressure of 760 mm Hg. Small deviations
from standard barometric pressure have little effect on the correction factors (e.g., the factor for
gas at 228C and 770 mm Hg is 1.0904).
84096_CH04_Chatburn.indd 124 6/18/10 11:00:59 AM
Gas Cylinders  125
Table 4–16 Physical Characteristics of Gases
Gas
Density
(g/L)
Critical
Temperature
(8C)
Critical
Pressure
(psi)
Boiling
Point (8C)
Melting
Point (8C)
Air 1.29 2140.7 546.8 — —
Oxygen 1.43 2118.8 730.6 2182.9 2218.4
Carbon dioxide 1.97 31.1 1,073.1 278.5
(sublimates)
256.6 (at
5.2 atm)
Nitrogen 1.25 2147.1 492.5 2195.8 2209.9
Table 4–17 Effects of Breathing Oxygen During Hyperbaric Therapy
Air
(at 1 atm)
Oxygen
(at 1 atm)
Oxygen
(at 3 atm)
Hemoglobin concentration 0.15 kg/L 0.15 kg/L 0.15 kg/L
Oxyhemoglobin 200 mL 204 mL 204 mL
Dissolved oxygen 2.85 mL/L 13.5 mL/L 42.3 mL/L
Total oxygen 203 mL/L 217 mL/L 246 mL/L
Table 4–18 Atmospheric Content, Percent by Volume
Nitrogen 78.084
Oxygen 20.947
Water 0.750
Carbon dioxide 0.031
84096_CH04_Chatburn.indd 125 6/18/10 11:00:59 AM
Intentional Blank 126
84096_CH04_Chatburn.indd 126 6/18/10 11:00:59 AM
CHAPTER
5
CHAPTER
5
Mechanical
Ventilation
84096_CH05_Chatburn.indd 127 6/17/10 1:32:03 PM
128  CHAPTER 5 Mechanical Ventilation
This chapter brings together a large variety of information concerning the
equipment and theory of mechanical ventilation. Some of the material has
been gathered from the manufacturers’ data sheets. We have attempted to
present the data in a uniform structure for easy comparison.
AirwAys ■
Table 5–l Dimensions of Oral Airways
Age ISO Size Length (mm) Guedel Berman
Neonate 4 40 Pink Pink
Infant 5 50 Blue Turquoise
Small child 6 60 Black Black
Child 7 70 White White
Small adult 8 80 Green Green
Medium adult 9 90 Yellow Yellow
Adult 10 100 Red Purple
Large adult 11 110 Orange Orange
Table 5–2 Approximate Equivalents of Various Tracheostomy Tube
Jackson Size Outside Diameter (mm) French Internal Diameter (mm)
00 4.3 13 2.5
0 5.0 15 3.0
1 5.5 16.5 3.5
2 6.0 18 4.0
3 7 21 4.5–5.0
4 8 24 5.5
5 9 27 6.0–6.5
6 10 30 7.0
7 11 33 75–8.0
8 12 37 8.5
9 13 39 9.0–9.5
10 14 42 10.0
11 15 45 10.5–11.0
12 16 48 11.5
Note: Since tube thicknesses vary from one manufacturer to another, these data are intended as a guide only.
84096_CH05_Chatburn.indd 128 6/17/10 1:32:03 PM
Airways  129
Table 5–3 Dimensions of Cuffless Pediatric Tracheostomy Tubes (in millimeters)
Size ID OD L
Portex
2.5 2.5 4.5 30
3.0 3.0 5.2 36
3.5 3.5 5.8 40
4.0 4.0 6.6 44
4.5 4.5 7.1 48
Shiley
3.0 3.0 4.5 39
3.5 3.5 5.2 40
4.0 4.0 6.0 41
4.5 4.5 6.5 42
5.0 5.0 7.1 44
ID 5 internal diameter; OD 5 outside diameter; L 5 length.
Table 5–4 Dimensions of LowPressure Cuffed Adult Tracheostomy Tubes (in milli
meters)
Size ID OD L
Kamen–Wilkenson (Bivona) (FomeCuff)
5 5.0 7.3 60
6 6.0 8.7 70
7 7.0 10 80
8 8.0 11 88
9 9.0 12.3 98
Portex
6 6.0 8.3 55
7 7.0 9.7 75
8 8.0 11 82
9 9.0 12.4 87
84096_CH05_Chatburn.indd 129 6/17/10 1:32:03 PM
130  CHAPTER 5 Mechanical Ventilation
Table 5–4 Dimensions of LowPressure Cuffed Adult Tracheostomy Tubes (in milli
meters) (continued)
Size ID OD L
Shiley
4 5.0 9.4 65
6 6.4 10.8 76
8 7.5 12.2 81
10 8.9 13.8 81
ID 5 internal diameter; OD 5 outside diameter; L 5 length.
Table 5–5 Laryngoscope Blades
Miller Wisconsin Macintosh
Age Size
Length
(mm) Size
Length
(mm) Size
Length
(mm)
Premature infant 0 75 0 75 — —
Infant 1 102 1 102 1 91
Child 2 150 2 135 2 100
Adult 3 190 3 162 3 130
Large adult — — 4 199 4 190
Table 5–6 Approximate Equivalents of Various Endotracheal Tube Sizing Methods
*
Diameter Sizing Equivalent
Connector
Size (mm)
Internal
(mm)
External
(mm)
Magill
Gauge
French
Gauge
Equivalent
Cuffs (in.)
2.5 4.0 12 3
3.0 4.5 00 12–14
3.5 5.0 0–0 14–16 3/16 4
4.0 5.5 0–1 16–18 3/16
4.5 6.0 1–2 18–20 1/4 5
5.0 6.5 1–2 20–22 1/4
5.5 7.0 3–4 22 1/4 6
6.0 8.0 3–4 24 1/4
6.5 8.5 4–5 26 1/4 7
84096_CH05_Chatburn.indd 130 6/17/10 1:32:03 PM
Airways  131
Table 5–6 Approximate Equivalents of Various Endotracheal Tube Sizing Methods
*
(continued)
Diameter Sizing Equivalent
Connector
Size (mm)
Internal
(mm)
External
(mm)
Magill
Gauge
French
Gauge
Equivalent
Cuffs (in.)
7.0 9.0 5–6 28 5/16
7.5 9.5 6–7 30 5/16 8
8.0 10.0 7–8 32 5/16 9
8.5 11.5 8 34 3/8
9.0 12.0 9–10 36 3/8 10
9.5 12.5 9–10 38 3/8 11
10.0 13.0 10–11 40 7/16 12
10.5 13.5 10–11 42 7/16
11.0 14.5 11–12 42–44 1/2 13
11.5 15.0 11–12 44–46 1/2
*
Since tube thicknesses vary from one manufacturer to another, these data are intended as a guide only.
Table 5–7 Guide to Choice of Endotracheal Tubes
*
French
Size
Internal
Diameter
(mm)
Oral
Length
(cm)
Nasal
Length
(cm)
Suction
Catheter
(French)
,1000 g 12 2.5 8 11 6
$1000 g 14 3.0 9 12 6
6 mo 16 3.5 10 14 8
1 yr 18–20 4.0–4.5 12 16 8
2 yr 22–24 5.0–5.5 14 17 8
2–4 yr 24–26 5.5–6.0 15 18 10
4–7 yr 26–28 6.0–6.5 16 19 10
7–10 yr 28–30 6.5–7.0 17 21 10
10–12 yr 30–32 7.0–7.5 20 23 10
12–16 yr 32–34 7.5–8.0 21 24 12
Adult (female) 34–36 8.0–8.5 22 25 12
Adult (male) 36–38 8.5–9.0 22 25 14
*
Endotracheal tube sizes will vary with body size and height. One size smaller and one size larger should be
available for individual variations.
84096_CH05_Chatburn.indd 131 6/17/10 1:32:03 PM
132  CHAPTER 5 Mechanical Ventilation
Table 5–8 Appropriate Suction Settings Vacuum Settings
Vacuum Settings
Age Portable (in. Hg) Wall (mm Hg)
Infant 3–5 60–100
Child 5–10 100–120
Adult 7–15 120–150
Figure 5–1 Graph for determining the appropriate length of insertion for infant endo
tracheal tubes. For infants weighing , 750 grams subtract 0.5 cm from predicted
length.
14
12
10
8
6
L
e
n
g
t
h
(
c
m
)
Body Weight (kg)
0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0
Nasatracheal
Oratracheal
Endotracheal (ET) tube size may be estimated for 1 to 12yearolds by
internal diameter of ET tube 1mm2 5
age 1yr2 1 16
4
Definition of terms ■
Note: In Tables 5–9a, 5–9b, and 5–9c and Figures 5–2 and 5–3, the use of
italics and subscripts differs from the symbol notation style used in this book.
84096_CH05_Chatburn.indd 132 6/17/10 1:32:04 PM
Definition of Terms  133
Figure 5–2 Schematic representation of the respiratory system, consisting of a flow
conducting tube (representing the airways) connected to a single elastic compartment
representing the lungs, surrounded by another elastic compartment representing the
chest wall. Pao is the pressure at the airway opening, Ppi is pressure in the intrapleural
space, Pbs is pressure on the body surface, Pa is alveolar pressure, and DPmus is
muscle pressure difference.
Reprinted with permission from Respir Care 51(12) (2006), 1458–1470.
Δ
Airway opening
Airways
Pleural space
Chest wall
Body surface
Lungs
P
AO
P
BS
P
mus
P
A
P
pl
84096_CH05_Chatburn.indd 133 6/17/10 1:32:04 PM
134  CHAPTER 5 Mechanical Ventilation
Figure 5–3 Diagram of the respiratory system with one compartment lung(s) and
chest wall subdivided into rib cage, diapgragmatic, and abdominal wall components.
The arrows labeled DPmus indicate the positive directions for the corresponding
muscle pressure differences. Pao = pressure at the airway opening. Pa = alveolar
pressure. P
pl
= pressure in the intrapleural space. DPmus = muscle pressure
difference. RC = rib cage. BS = body surface. ab = abdomen. di = diaphragm.
Reprinted with permission from Respir Care 51(12) (2006), 1458–1470.
Δ
Airway opening
Airways
Pleural space
Chest wall
Body surface
Lungs
Stomach
Diaphragm
P
AO
P
BS
P
A
P
mus
RC
ΔP
mus
ab
ΔP
mus
di
P
ab
P
pl
84096_CH05_Chatburn.indd 134 6/17/10 1:32:04 PM
Definition of Terms  135
Table 5–9A Summary of Symbol Conventions
Entity Subtype Style Examples
Variable Primary Italic, upper case P pressure
V volume
V
#
flow
C concentration
T temperature
Difference
(difference
between points
in space)
Italic, upper case, delta
symbol
DP pressure at one point minus
pressure at another point on
the system
Change
(change rela
tive to a refer
ence point)
Italic, lower case p pressure measured relative to
an operating point
Argument (used
with variables
only; if no argu
ment explic
itly stated, then
time is implied)
Not applicable Style of entity P(t) pressure as a function of time
v(p) change in volume as a func
tion of change in pressure
Z(jv) impedance (complex number;
function of angular frequency)
Property Material Bold, usually Greek e elasticity
h viscosity
Structural Bold, usually English C compliance
R resistance
t time constant
I inertance
D diffusing capacity
System Bold, upper case may be
English and Greek
Z(jv) impedance (complex number;
function of angular frequency)
Characteristic General wave
form
Upper and lower case PEEP positive end expiratory
pressure
MAP mean arterial pressure
WOB work of breathing
PIP peak inspiratory pressure
System
response
Upper and lower case FEV
1
forced expiratory volume in
the first second
MV minute ventilation
FVC forced vital capacity
Cdyn dynamic compliance
Reprinted with permission from Respir Care 51(12) (2006), 1458–1470.
84096_CH05_Chatburn.indd 135 6/17/10 1:32:04 PM
136  CHAPTER 5 Mechanical Ventilation
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84096_CH05_Chatburn.indd 136 6/17/10 1:32:04 PM
Definition of Terms  137
Reprinted with permission from Respir Care 51(12) (2006), 1458–1470.
Table 5–9C
Alveolar Ventilation (V
#
A)
The cumulative volume of fresh gas entering the gasexchanging portion of
the lungs (respiratory bronchioles and alveoli) per minute. Alveolar ventila
tion is calculated as
V
#
A 5 1VT 2 VD2 3 f
b
where
V
#
A 5 alveolar ventilation (L/min)
VT 5 tidal volume (L)
VD 5 dead space volume (L)
f
b
5 breathing frequency (breaths/min)
84096_CH05_Chatburn.indd 137 6/17/10 1:32:05 PM
138  CHAPTER 5 Mechanical Ventilation
Compliance
A property that describes the elastic behavior of a structure. It quantifies the
volume change that results from a change in pressure difference across a sys
tem at rest. Compliance can be calculated as the ratio of the change in vol
ume to the change in pressure difference occurring between instants in which
the system is completely at rest:
C 5
DV
D1PI 2 PO2
(5–1)
where
C 5 compliance (L/cm H
2
O)
DV 5 change in volume (L)
PI 5 pressure inside the system
PO 5 pressure on the outside surface of the system
Note: The symbol D indicates a change in the variable within the parenthe
ses.
The system for which compliance is evaluated is defined by the points
between which the pressure is measured. For example, we can evaluate the
compliance of the physiologic system, which comprises the lungs and chest
wall. The compliance of the lung is defined as
CL 5
DVL
D1PAO 2 PPL2
(5–2)
where
CL 5 lung compliance (L/cm H
2
O)
DVL 5 the change in lung volume (L)
PAO 5 pressure at the airway opening (cm H
2
O)
PPL 5 intrapleural pressure (cm H
2
O) (Clinically, changes in PPL are
estimated from changes in esophageal pressure.)
For the chest wall, the equation is
CW 5
DVW
D1PPL 2 PBS2
(5–3)
84096_CH05_Chatburn.indd 138 6/17/10 1:32:05 PM
Definition of Terms  139
where
CW 5 chest wall compliance (L/cm H
2
O)
DVW 5 the change in the volume of the thoracic cavity (equal to VL if
there is no pneumothorax)
PBS 5 pressure at the body surface (cm H
2
O)
Also,
CRS 5
DVL
D1PAO 2 PBS2
(5–4)
where
CRS 5 total respiratory system compliance (L/cm H
2
O)
Equations (5–2), (5–3), and (5–4) can be combined to show that
1
CRS
5
1
CL
1
1
CW
or
CRS 5
CL 3 CW
CL 1 CW
Another system for which a knowledge of compliance is useful is the ven
tilator circuit attached to the patient’s airway. We can compute this patient
circuit compliance as
CPC 5
tidal volume
D1PAO 2 PBS2
5
tidal volume
PIP 2 PEEP
where
CPC 5 patient circuit compliance
(PAO 2 PBS) 5 the difference between pressure at the airway opening
and pressure on the body surface, with the patient con
nection port occluded
PIP 5 peak inspiratory pressure with patient connection port
occluded
PEEP 5 positive endexpiratory pressure (if any) with patient
connection port occluded
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140  CHAPTER 5 Mechanical Ventilation
Compliance evaluated by equations (5–1) to (5–4) is referred to as static
compliance in the literature. In practice, the equations are sometimes applied
to the respiratory system during breathing, and the variables V and P are
measured at instants when the flow at the airway opening is zero rather
than when the system is at rest. Compliance calculated in this way is called
dynamic compliance.
Static and dynamic compliances are given various symbols: For static com
pliance we shall use C; for dynamic compliance we shall use Cdyn(f
b
), in
which f
b
indicates that Cdyn is evaluated at particular breathing frequencies.
If equation (5–2) is evaluated for the lungs when they are completely at rest
(CL) and during breathing at different frequencies (CdynL(f
b
)), and if the val
ues obtained under both sets of conditions are the same (within 20%), then
we can infer that the lungs have a uniform distribution of mechanical time
constants. Such lungs can therefore be characterized by a single compliance
(CL) and a single resistance (RL) at all breathing frequencies.
If CdynL(f
b
) and CL are not equal at all frequencies (i.e., Cdyn(f
b
) decreases
as f
b
increases), then the lungs have a nonuniform distribution of mechani
cal time constants (i.e., different regions of the lungs have different products
of local flow resistance and local static compliance). In this case CdynL(f
b
)
describes the elastic load presented by the system at a particular breathing
frequency and reflects both the resistances and compliances of all the lung
regions.
During mechanical ventilation, static respiratory system compliance can be
evaluated using the equation
CRS 5
VT
PPLT 2 PEEP
where
CRS 5 static respiratory system compliance (L/cm H
2
O)
VT 5 tidal volume delivered to patient (L)
PPLT 5 proximal airway plateau pressure (cm H
2
O)
PEEP 5 positive endexpiratory pressure in the lungs (cm H
2
O)
Another index, the dynamic characteristic, is often confused with dynamic
compliance:
dynamic characteristic 5
VT
PIP 2 PEEP
84096_CH05_Chatburn.indd 140 6/17/10 1:32:05 PM
Definition of Terms  141
where PIP is peak inspiratory pressure. This index is not compliance because
the pressure change has a component due to airway resistance (i.e., PIP
occurs while flow is still being delivered to the airway opening). For a
given tidal volume and inspiratory flow rate, the dynamic characteristic will
decrease as either airway resistance increases or compliance decreases. It
should be interpreted as an index of the load experienced by the ventilator.
Compressor
A device whose internal volume can be changed to increase the pressure of
the gas it contains. In mechanical ventilation, a compressor is the device pri
marily responsible for generating the pressure necessary to force gas into the
patient’s lungs.
Cycle
To cycle the ventilator means to terminate the inspiratory phase.
Dead Space Volume (Vd)
Dead space volume is the respired gas volume that does not participate in gas
exchange. This volume is commonly referred to as physiologic dead space.
One component of the physiologic dead space can be identified with the
conducting (nongasexchanging) airways extending from the upper airway
to the respiratory bronchioles. This component is called the anatomic dead
space. Normal physiologic dead space volume is roughly estimated as 2 mL/
kg (1 mL/lb) of ideal body weight.
Duty Cycle
A term applied to a device that functions intermittently rather than con
tinuously. It refers to the ratio of the time that a device operates to its total
cycle time expressed as a percent (e.g., the “% inspiration” of the Siemens
Servo i Ventilator). As it applies to mechanical ventilators, the duty cycle
can be defined as
duty cycle 1%2 5
f 3 TI
60
3 100% 5
TI
TCT
3 100% 5
I
I 1 E
3 100%
and
I
E
5
duty cycle
100% 2 duty cycle
84096_CH05_Chatburn.indd 141 6/17/10 1:32:06 PM
142  CHAPTER 5 Mechanical Ventilation
where
f 5 ventilator frequency (breaths/min)
TI 5 inspiratory time (s)
TCT 5 total cycle time, or time for one ventilatory cycle of one
inspiration and one expiration (s)
I 5 numerator of inspiratory:expiratory ratio
E 5 denominator of inspiratory:expiratory ratio
Elastance (E)
The reciprocal of compliance (C):
E 5
1
C
Equation of Motion
The respiratory system can be modeled as a single flowconducting tube con
nected in series to a single elastic compartment (referred to as a single com
partment model). The equation that relates pressure, volume, and flow (all of
which are functions of time) for this model is called the equation of motion.
One version of this equation is
During Inspiration:
PMUS 1 PTR 5 1ETR 3 V2 1 1RTR 3 V
#
2 1 aPEEP
5
V
CRS
1 1RRS 3 V
#
2 1 aPEEP
During Expiration when Pmus and Ptr 5 0:
1ERS 3 V2 1 aPEEP 5 21RRS 3 V
#
2
where
aPEEP 5 auto PEEP, equal to endexpiratory alveolar pressure minus set
PEEP
PMUS 5 the effective pressure difference generated by the respiratory
muscles
PTR 5 the change in transrespiratory system pressure (e.g., the
pressure generated by a mechanical ventilator) measured rela
tive to endexpiratory pressure
84096_CH05_Chatburn.indd 142 6/17/10 1:32:06 PM
Definition of Terms  143
CRS 5 compliance of the respiratory system
V 5 volume change measured relative to endexpiratory volume
(i.e., functional residual capacity [FRC])
RRS 5 resistance of the respiratory system
V
#
5 change in flow measured relative to endexpiration (i.e.,
relative to zero flow)
ERS 5 elastance of the respiratory system
The system described by the equation of motion is defined by the points in
space between which the pressure difference is measured. Thus, the respira
tory system (along with respiratory system compliance and resistance) is
defined in terms of transrespiratory pressure (pressure at the airway opening
minus pressure at the body surface); the lungs (along with lung compliance
and resistance) are defined in terms of transpulmonary pressure (pressure at
the airway opening minus pressure in the pleural space); and the chest wall
(along with chest wall compliance and resistance) is defined in terms of
transmural pressure (pressure in the pleural space minus pressure at the body
surface). The equation of motion may also be expressed using transpulmo
nary pressure (with lung compliance and resistance) or transmural pressure
(with chest wall compliance and resistance).
Expiratory Time (Te)
The time interval from the start of expiratory flow to the start of inspiratory
flow. Expiratory time is the total cycle time minus the inspiratory time. For
volumelimited, constantflow ventilators, TE may be calculated from the fol
lowing equation (assuming there is no inspiratory hold):
TE 5 TI 2 TE 5
60
f
2
VT
V
#
I
where
TE 5 expiratory time (s)
TI 5 inspiratory time (s)
TCT 5 total cycle time (s)
f 5 ventilatory frequency (breaths/min)
VT 5 tidal volume (L)
V
#
I 5 inspiratory flow rate (L/s)
84096_CH05_Chatburn.indd 143 6/17/10 1:32:06 PM
144  CHAPTER 5 Mechanical Ventilation
If the I:E ratio is known, TE is calculated as
TE 5
TCT 3 E
I 1 E
5
60 3 E
f 3 1I 1 E2
where
TE 5 expiratory time (s)
TCT 5 total cycle time (s)
I 5 numerator of I:E ratio
E 5 denominator of I:E ratio
f 5 ventilatory frequency (breaths/min)
Frequency, Breathing (f
b
)
The number of breathing cycles or breaths per unit time (usually minutes)
produced spontaneously or initiated by the patient or by the ventilator.
Frequency, Ventilator (f)
Breathing cycles or breaths per unit time (usually minutes) produced by a
ventilator.
Frequency, Ventilator (as related to gas exchange)
During volumelimited, controlled ventilation, the arterial carbon dioxide
tension (PaCO
2
) can be controlled by the ventilator frequency, since PaCO
2
is
inversely proportional to alveolar ventilation. Assuming steady state and the
body’s metabolic production of carbon dioxide remains constant, the ventila
tor frequency required to effect a desired PaCO
2
is given by
new f 5 old f × (old VA / new VA) × (old PaCO
2
/ new PaCO
2
)
where
VA 5 alveolar volume 5 tidal volume minus dead space volume
For example, suppose a ventilator frequency of 10 bpm results in a PaCO
2
of
60 mm Hg, and a PaCO
2
of 40 mm Hg is desired without making a change in
VT, then
new f 5 10 × 1 × 60/40 5 15 breaths/min
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Definition of Terms  145
Gauge Pressure
Gauge pressure is the difference between the pressure of a fluid at some
point and atmospheric pressure. Gauge pressure is denoted by a lower case g
(e.g., psig or cm H
2
O, g).
Inspiration
The act of inflating the lungs. Inspiration only occurs while there is flow into
the airway opening.
Inspiratory:Expiratory Time Ratio (I:E)
Ratio of the inspiratory time to the expiratory time:
I:E 5 I/E
In the above equation, I and E can be expressed using either of the following
conventions:
I 5 TI/TE (for example, 2:1)
E 5 1
or
I 5 1
E 5 TE/TI, (for example, 1:3, 1:0.5)
where
TI 5 inspiratory time
TE 5 expiratory time
Inspiratory Flow (V
#
I)
The flow of gas measured at the airway opening during inspiration. For vol
ume control modes, mean inspiratory flow rate can be calculated as
V
#
I 5
VT
TI
where
V
#
I 5 inspiratory flow (L/min)
VT 5 tidal volume (L)
TI 5 inspiratory time (min)
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146  CHAPTER 5 Mechanical Ventilation
Inspiratory Hold
A maneuver used during mechanical ventilation. It is characterized by a
delay between the end of inspiratory flow and the beginning of expiratory
flow. This delay period extends the inspiratory time.
Inspiratory Time (Ti)
The time interval from the start of inspiratory flow to the start of expiratory
flow. Note that TI can extend beyond the point when inspiration ends as
when an inspiratory hold is used. Inspiratory time is equal to the total cycle
time (TCT) minus the expiratory time. For volumelimited constant flow
ventilators, TI may be calculated from the following equation (assuming
there is no inspiratory hold):
TI 5
VT
V
#
I
where
TI 5 inspiratory time (s)
VT 5 tidal volume (L)
V
#
I 5 inspiratory flow (L/s)
If the I/E ratio is known, TI is given by
TI 5
TCT 3 I
I 1 E
5
60 3 I
f 3 1I 1 E2
where
TI 5 inspiratory time (s)
TCT 5 total cycle time (s)
I 5 numerator of I:E ratio
E 5 denominator of I:E ratio
f 5 ventilatory frequency (breaths/min)
Inspiratory Relief Valve
A unidirectional valve designed to admit air to the patient system when the
patient inspires spontaneously and the supply of inspiratory gases from the
ventilator is inadequate.
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Definition of Terms  147
Inspiratory Triggering Flow (V
#
TR)
The flow that must be generated by the patient at the patient connection port
to produce a drop in pressure (i.e., below the inspiratory triggering pressure)
sufficient to initiate the ventilator inspiratory phase.
Inspiratory Triggering Pressure (Ptr)
The airway pressure at the patient connection port that must be generated by
the patient to initiate the ventilator inspiratory phase.
Inspiratory Triggering Response Time (Ttr)
Time delay between the satisfaction of the inspiratory triggering pressure,
flow, or volume requirements and the start of inspiratory flow.
Inspiratory Triggering Volume (Vtr)
The volume change of the patient system plus the patient’s lungs required to
initiate the ventilator inspiratory phase.
Maximum Safety Pressure (Ps max)
The highest gauge pressure that can be attained in the patient system during
malfunction of the ventilator, but with functioning safety mechanisms (i.e.,
the valve opens).
Maximum Working Pressure (Pw max)
The highest gauge pressure that can be attained in the patient system during
the inspiratory phase when the ventilator is functioning normally. (This may
be limited by ventilator adjustments to less than PS MAX.)
Mean Airway Pressure (Paw)
The average pressure that exists in the airways over a given integral number
of cycles during mechanical ventilation. For a periodic waveform, Paw is
defined as
Paw 5
area under pressure curve for one cycle
total cycle time
84096_CH05_Chatburn.indd 147 6/17/10 1:32:07 PM
148  CHAPTER 5 Mechanical Ventilation
In general,
Paw 5
k1PIP 2 PEEP2 3 TI
TCT
1 PEEP
where
Paw 5 mean airway pressure (cm H
2
O)
k 5 waveform constant. The value of k depends on the shape of the
airway pressure curve.
PIP 5 peak inspiratory pressure (cm H
2
O)
PEEP 5 positive endexpiratory pressure (cm H
2
O)
TI 5 inspiratory time (sec)
TCT 5 total cycle time (sec)
For a constant flow ventilator with a periodic triangular pressure waveform
and negligible expiratory resistance, the value of k in the preceding equation
is
1
2
. For a periodic rectangular pressure waveform, the value of k is 1.0.
Minimum Safety Pressure (Ps min)
The most negative gauge pressure that can be attained in the patient system
during malfunction of the ventilator, but with functioning safety mechanisms.
Minimum Working Pressure (Pw min)
The most negative gauge pressure that can be attained in the patient system
during the expiratory phase when the ventilator is functioning normally.
(This may be limited by ventilator adjustment to a pressure that is greater
than PS MIN.)
Minute Volume (V
#
E; Also, Minute Ventilation)
The cumulative volume of gas expired per minute by the patient:
V
#
E 5 VT 3 f
where
V
#
E 5 minute volume (L/min)
VT 5 tidal volume (L)
f 5 ventilatory frequency (breaths/min)
84096_CH05_Chatburn.indd 148 6/17/10 1:32:07 PM
Definition of Terms  149
Motor
Anything that produces motion. As it relates to a mechanical ventilator, the
motor is the device used to drive the compressor.
Patient System
That part of the ventilator gas system (up to the patient connection point)
through which respired gas travels at respiratory pressures.
Pendelluft
Gas flow between different regions of the lung caused by inequalities of
mechanical time constants among these regions.
Plateau Pressure (PPlt)
That portion of the proximal airway pressure waveform generated during
positive pressure ventilation that is due solely to the elastic recoil of the total
respiratory system (chest wall plus lungs). During volumelimited ventila
tion, this pressure is generated in the lung by delivering a preset volume and
delaying the opening of the exhalation valve until all airflow in the lungs
has ceased. Once volume delivery from the ventilator has stopped, airway
pressure drops from its peak value to the plateau value as gas is redistributed
within the lung.
Power, Ventilator (W
#
)
The rate of work performed by the ventilator on the patient:
W
#
5 0.098 3 Paw 3 V
#
where
W
#
5 instantaneous ventilator power (watts)
Paw 5 airway pressure (cm H
2
O)
V
#
5 flow (L/s)
Note: The constant 0.098 is used to convert cm H
2
O ? L/s to watts.
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150  CHAPTER 5 Mechanical Ventilation
Pressure Drop
The difference in pressure between a point of higher pressure and another of
lower pressure.
Pressure Hold
One type of proximal airway pressure pattern produced by a positive pressure
ventilator. It is characterized by a rise in inspiratory pressure to some peak
value that is deliberately sustained for the duration of the inspiratory time.
Resistance (Flow Resistance)
A system property that relates the pressure drop causing flow through the
system. For a viscous gas flowing through a tube, resistance arises from the
interaction among gas molecules and between gas molecules and the tube
wall. Resistance can be calculated as the change in pressure difference pro
ducing flow divided by the change in flow, where changes in pressure and
flow are measured between points in time of equal lung volume:
R 5
D1P
1
2 P
2
2
DV
# (5–5)
where
R 5 resistance (cm H
2
O/L/s)
D(P
1
– P
2
) 5 change in pressure difference across the system from some
point 1 to another point 2 (cm H
2
O)
DV
#
5 change in flow (L/s)
The system for which resistance is calculated is defined by the points
between which the pressure difference is measured. For example, airway
resistance (Raw) is a measure of the flow resistance between the airway
opening and the alveoli. If measurements of flow and pressure are made at
points of equal lung volume (so that pressure changes due to elastic recoil are
canceled out), airway resistance can be estimated by the equation
Raw 5
D1PAO 2 PA2
DV
# (5–6)
where
Raw 5 airway resistance (cm H
2
O/L/s)
PAO 5 proximal airway pressure (cm H
2
O)
84096_CH05_Chatburn.indd 150 6/17/10 1:32:07 PM
Definition of Terms  151
V
#
5 change in flow (L/s)
PA 5 alveolar pressure (cm H
2
O)
Also
RL 5
D1PAO 2 PPL2
DV
# (5–7)
where
RL 5 lung resistance (cm H
2
O/L/s)
DV
#
5 change in flow (L/s)
PPL 5 intrapleural pressure (cm H
2
O)
Another example is total respiratory resistance, which includes Raw and
other resistances due to pulmonary and chest wall tissue motions. The
required pressure difference is between the airway opening and the body
surface. During mechanical ventilation with a constant flow generator, the
change in this pressure difference can be estimated as peak inspiratory pres
sure minus plateau pressure. Therefore,
RRS 5
PIP 2 PPLT
V
#
I
(5–8)
where
RRS 5 respiratory system resistance (cm H
2
O/L/s)
PIP 5 peak inspiratory pressure (cm H
2
O)
PPLT 5 plateau pressure (cm H
2
O)
V
#
I 5 set inspiratory flow rate (L/s)
The major component of RRS and RL is Raw. Therefore, in practice, they are
often used interchangeably as close estimates of each other.
Sigh, Ventilator
A deliberate increase in tidal volume for one or more breaths at intervals.
During mechanical ventilation, the sigh volume generally used is twice the
tidal volume. During normal spontaneous breathing, sighs occur 6–10 times
per hour.
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152  CHAPTER 5 Mechanical Ventilation
Specific Compliance (C/Vl)
A parameter used to characterize the elastic behavior of the material from
which a system is made. This is in contrast to compliance, C, which char
acterizes the elastic behavior of a particular system constructed from the
material. Specific compliance is defined as C divided by the total volume of
the structure at which C is evaluated. Specific compliance provides a means
of comparing the elastic behavior of the pulmonary parenchyma of lungs of
different sizes.
Tidal Volume (Vt)
The volume change of the patient’s lungs during spontaneous breathing or
mechanical ventilation. For volumelimited ventilation, the tidal volume is
controlled by ventilator settings and remains relatively constant while the
pressure necessary to deliver the volume varies with changing lung mechan
ics. The tidal volume delivered to the patient is usually less than the volume
set on the ventilator due to the volume lost (compressed) in the patient sys
tem:
tidal volume 5 set machine volume – compressed volume
The compressed volume can be calculated if the compliance of the patient
circuit (CPC) is known (see Compliance). Once the patient is connected to
the ventilator, the compressed volume is determined by the change in airway
pressure during inspiration. For example,
compressed volume 5 (PIP – PEEP) × CPC
where
PIP 5 peak inspiratory pressure PEEP 5 endexpiratory pressure
During mechanical ventilation, respiratory system compliance affects the
change in airway pressure and hence the volume of gas compressed in the
patient circuit. If an inspiratory hold maneuver is used, the following equa
tion applies:
tidal volume 5 °
1
1 1
CPC
CRS
¢ 3 set machine volume
where
CRS 5 respiratory system compliance
84096_CH05_Chatburn.indd 152 6/17/10 1:32:08 PM
Definition of Terms  153
If an inspiratory hold is not used, substitute the patient’s dynamic character
istic for CRS in this equation.
During pressure control ventilation, the proximal airway pressure pattern
is controlled by ventilator settings and remains relatively constant while
the tidal volume varies with changing lung mechanics. The change in lung
volume caused by a step change in airway pressure (rectangular pressure pat
tern) is given by
V1t2 5 C 3 DP 3 11 2 e
2t>1R3C2
2 5 CDPa1 2
1
e
t>1R3C2
b
where
V(t) 5 lung volume (L) as a function of time (t). If time 5 inspiratory
time then V(t) 5 tidal volume.
C 5 total respiratory system compliance (L/cm H
2
O)
DP 5 step change in airway pressure, or PIP 2 PEEP (cm H
2
O)
e 5 the base of the natural logarithms (approximately 2.72)
t 5 the time interval (in seconds) from the initiation of the step
change in airway pressure; inspiratory time
R 5 total respiratory system resistance (cm H
2
O/L/s)
Note: This equation is derived from the equation describing the change in
alveolar pressure in response to a step change in airway pressure (see Time
Constant).
Time Constant (Resistance 3 Compliance)
A measure of the time (usually seconds) necessary for an exponential func
tion of time to attain 63% of its value at time equal to infinity. For example,
in physiology the respiratory system is often modeled as being composed of
a single compliance (representing the chest wall and the alveoli) and a single
resistance (representing the airways). If a step input (instantaneous change)
of pressure is applied to the airway opening of such a model, the pressure
rise in the compliant chamber will be an exponential function of time. To
illustrate this, consider the relation governing the mechanics of a completely
passive total respiratory system (i.e., one in which all the respiratory muscles
are completely relaxed or paralyzed):
PTR 5
V
C
1 R 3 V
#
(5–9)
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154  CHAPTER 5 Mechanical Ventilation
in which PTR is transrespiratory system pressure, that is, the difference
between the pressure at the airway opening and the pressure on the body
surface (usually atmospheric pressure). This equation states that the pressure
necessary for inflation or deflation of the lungs depends on the compliance of
the total respiratory system (C), tidal volume volume (V), resistance (R), and
gas flow rate into the lungs (V
#
L). For a step change in airway pressure (e.g.,
∆PAO 5 PIP 2 PEEP), equation (5–9) can be solved for alveolar (lung) pres
sure as a function of time, assuming resistance and compliance are constant:
PA1t2 5 DPAO 3 11 2 e
2t>1R3C2
2 (5–10)
where
PA(t) 5 alveolar pressure as a function of time (t)
DPAO 5 change in pressure at the airway opening
e 5 the base of the natural logarithms (approximately 2.72)
t 5 the time interval (in seconds) from the initiation of the step
change in airway pressure; inspiratory time
This states that the alveolar pressure (the pressure in the compliant cham
ber in our model) will undergo an exponential change in response to a step
change of ∆P in airway pressure. If both sides of equation (5–10) are mul
tiplied by C, we get the equation for lung volume as a function of time (see
Tidal Volume).
The product of resistance and compliance, RC (which has the dimensions
of time), appears as a fundamental quantity in this equation and is there
fore given its own name, the time constant. To appreciate the properties of
the time constant, consider the values equation (5–10) will have at specific
instants of time. When t is equal to R × C, the term t/RC equals 1 and the
expression 1 2 e
2t/R 3 C
5 1 2 2.72
21
5 1 2 0.37 5 0.63. Thus, the alveo
lar pressure is equal to 63% of the forcing pressure, ∆P, when t equals RC. If
t is equal to 2RC or two time constants, the alveolar pressure will be 86.5%
of the forcing pressure. Alveolar pressure is generally considered to be at its
steadystate value when t is equal to 5RC. At this time also, PA is considered
in equilibrium with the pressure at the airway opening, since all flow through
the airways has essentially ceased. Expressing t as a multiple of the time
constant is thus a convenient method of predicting the time necessary for the
system to respond to a step input of pressure. Conversely, the time necessary
to attain 63% of the final response (which may be measured experimentally)
is equal to the product of R and C and thus gives a mechanical characteristic
84096_CH05_Chatburn.indd 154 6/17/10 1:32:08 PM
Definition of Terms  155
of the system. Figure 5–4 shows the fraction of ∆P that exists in the lungs at
the end of time constants 0 through 5.
Figure 5–4 Time constant curves. Curve A corresponds to the inspiratory lung pres
sure and volume and expiratory flow. Curve B corresponds to expiratory lung pressure
and volume and inspiratory flow.
Time Constants
0 1 2 3 4 5 6
100
80
60
40
20
A
B
A
l
v
e
o
l
a
r
P
r
e
s
s
u
r
e
(
%
∆
P
)
Torr
Unit of pressure named in honor of Evangelista Torricelli, who invented
the mercury barometer. The torr is defined as exactly equal to 1/760 of a
standard atmosphere. It is generally considered to be equal to a millimeter of
mercury, although the latter is gravitydependent.
Total Cycle Time (TCT)
The time necessary for one complete respiratory cycle.
TCT 5 TI 1 TE 5
60
f
where
TCT 5 total cycle time (s)
TI 5 inspiratory time (s)
TE 5 expiratory time (s)
f 5 ventilatory frequency (breaths/min)
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156  CHAPTER 5 Mechanical Ventilation
Trigger
To trigger the ventilator means to initiate the inspiratory time.
Work, Ventilator (W)
Work performed by the ventilator on the patient:
W 5 0.098 3
#
P 3 V
#
dt
where
W 5 work (joules)
P 5 pressure (cm H
2
O)
V
#
5 flow (L/s)
0.098 5 constant to convert cm H
2
O ? L to joules
ClAssifying moDes of meChAniCAl ■
VentilAtion
A “mode” of mechanical ventilation can be generally defined as a predeter
mined pattern of interaction between a ventilator and a patient. There are
over 100 names for modes of ventilation on commercially available mechani
cal ventilators. Neither the manufacturing community nor the medical com
munity has developed a standard taxonomy for modes. However, we present
here an approach to both defining and classifying the major characteristics
of modes. It consists of 10 fundamental aphorisms that constitute the compo
nents of a practical taxonomy and ultimately, an adequately explicit defini
tion of “mode.” The aphorisms are given in outline form below:
The Breath. 1. The normal breathing pattern is cyclic and thus a breath
is conveniently characterized by the phases of the flow–time wave
form at the airway opening.
The positive phase of the flow waveform is designated inspira 1.1.
tion (inspiratory phase). The negative phase of the flow wave
form and the remaining time until the next inspiration indicates
expiration (expiratory phase).
Inspiration (inspiratory time) includes the phase of posi 1.1.1.
tive flow and any period of zero flow before flow goes
negative.
84096_CH05_Chatburn.indd 156 6/17/10 1:32:09 PM
Classifying Modes of Mechanical Ventilation  157
Expiration (expiratory time) includes the phase of nega 1.1.2.
tive flow and any period of zero flow before flow goes
positive for the next cycle.
The Assisted Breath. 2. A ventilator can provide all of the mechanical
work of inspiration or only a portion of it.
An assisted breath is one for which the ventilator does some or 2.1.
all of the work of breathing (i.e., transrespiratory pressure rises
during inspiration or falls during expiration).
An unassisted breath is one for which the ventilator simply pro 2.2.
vides flow at the rate required by the patient’s inspiratory effort
(i.e., transrespiratory system pressure stays constant throughout
the breath).
A loaded breath is one for which the patient does work on the 2.3.
ventilator (i.e., transrespiratory pressure falls during inspiration
or rises during expiration).
The Control Variable. 3. Ventilators operate by manipulating a con
trol variable. For simple control systems, where pressure, volume, or
flow is preset, the control variable is the independent variable in the
equation of motion for the respiratory system. In more complicated
schemes, the control variable is identified according to the feedback
loop that is predominant within a breath (not between breaths). For
example, with Proportional Assist, pressure, volume, and flow all vary
during the breath, and none of them are preset. However, the target
ing scheme is designed to control pressure such that it satisfies the
equation of motion for preset values of respiratory system elastance
and resistance that are to be supported for any instantaneous values
of inspiratory flow and volume generated by the patient’s inspiratory
effort.
For historical reasons and to simplify descriptions of ventilator 3.1.
operation, pressure and volume are considered to be the control
variables.
Volume is measured and controlled either directly (e.g., 3.1.1.
by the excursion of a piston) or indirectly (by integration
of the flow signal).
While a ventilator can control only one variable, it may switch 3.2.
from volume control to pressure control or vice versa during an
individual inspiration.
84096_CH05_Chatburn.indd 157 6/17/10 1:32:09 PM
158  CHAPTER 5 Mechanical Ventilation
Trigger and Cycle Variables. 4. During mechanical ventilation, an
individual breath is classified by the criteria that start (trigger) and end
(cycle) the inspiratory phase.
Inspiratory time is determined by the cycle criterion. 4.1.
Expiratory time is determined by the trigger criterion. 4.2.
The duration of the breath (total cycle time) is the sum of the 4.3.
inspiratory and expiratory times.
These criteria may be set either as static values for each breath 4.4.
(e.g., operator preset) or as dynamic values determined by algo
rithms during the course of ventilation.
Patient and Machine Triggering and Cycling. 5. Trigger and cycle cri
teria can be grouped into two categories: machine initiated and patient
initiated.
Machineinitiated criteria are those that determine the start and 5.1.
end of the inspiratory phase independent of the patient. This
means that the ventilator determines the inspiratory time and
expiratory time, or alternatively, the inspiratory time and fre
quency.
Machine triggering 5.1.1. criteria include but are not limited
to:
Frequency 5.1.1.1.
Expiratory time 5.1.1.2.
Minimum minute ventilation 5.1.1.3.
Machine cycling 5.1.2. criteria include:
Inspiratory time 5.1.2.1.
Tidal volume 5.1.2.2.
Patientinitiated criteria are those that affect the start and end of 5.2.
the inspiratory phase independent of any machine settings for
inspiratory and expiratory time. This means that the patient may
affect the inspiratory time and frequency.
Patient triggering 5.2.1. criteria include but are not limited to:
Transrespiratory system pressure 5.2.1.1.
Inspiratory volume 5.2.1.2.
Inspiratory flow 5.2.1.3.
84096_CH05_Chatburn.indd 158 6/17/10 1:32:09 PM
Classifying Modes of Mechanical Ventilation  159
Diaphragmatic electromyogram 5.2.1.4.
Transthoracic electrical impedance 5.2.1.5.
Patient cycling 5.2.2. criteria include:
Transrespiratory system pressure 5.2.2.1.
Inspiratory flow 5.2.2.2.
Mandatory and Spontaneous Breaths. 6. An individual breath is clas
sified as being mandatory or spontaneous. A mandatory breath is one
for which the start or end of inspiration (or both) is determined by the
ventilator, according to a preset schedule (e.g., preset frequency or
minute ventilation). Mandatory breaths will begin and end without a
signal from the patient but may also be synchronized with a patient
signal (e.g., change in baseline pressure or flow). A spontaneous
breath is one for which the start and end of inspiration is determined
by the patient. Triggering and cycling of a spontaneous breath may
occur due to a signal derived from active inspiratory or expiratory
efforts or a signal derived from the passive behavior of the respiratory
system (e.g., change in pressure or flow during inspiration or expira
tion governed by the time constant of the respiratory system).
Mandatory breaths are machine triggered or machine cycled or 6.1.
both.
Spontaneous breaths are both patient triggered and patient 6.2.
cycled.
The Breath Sequence. 7. A breath sequence is a particular pattern
of mandatory and/or spontaneous breaths. Breath sequences can be
grouped into three categories:
Continuous mandatory ventilation (CMV): 7.1. Mandatory
breaths are patient triggered for every patient effort that satis
fies the mandatory breath trigger criteria. In the absence of
patient triggering, mandatory breaths will be machine triggered.
Spontaneous breaths may occur during a mandatory inspiration
but not between mandatory breaths.
Intermittent mandatory ventilation (IMV): 7.2. Mandatory breaths
are patient triggered if the patient effort satisfies the mandatory
breath trigger criteria and it occurs in a brief trigger window,
which typically occurs at the end of the expiratory time allowed
by the preset mandatory breath frequency. Otherwise they are
84096_CH05_Chatburn.indd 159 6/17/10 1:32:09 PM
160  CHAPTER 5 Mechanical Ventilation
machine triggered, and spontaneous breaths may occur between
mandatory breaths.
If the frequency of either spontaneous breaths or patient 7.2.1.
triggered mandatory breaths is too low, mandatory
breaths may be machine triggered. Three common varia
tions of IMV are:
Mandatory breaths are always delivered at the 7.2.1.1.
set frequency.
Mandatory breaths are delivered only when the 7.2.1.2.
spontaneous breath frequency falls below the
set frequency.
Mandatory breaths are delivered only when the 7.2.1.3.
spontaneous minute ventilation (i.e., product of
spontaneous breath frequency and spontaneous
breath tidal volume) drops below a preset or
computed threshold (also known as mandatory
minute ventilation).
Spontaneous breaths may occur during a mandatory 7.2.2.
inspiration.
Continuous spontaneous ventilation (CSV): 7.3. Every breath is
spontaneous.
The Ventilatory Pattern. 8. A ventilatory pattern is a specification for a
particular control variable associated with a particular breath sequence.
There are five basic ventilatory patterns:
Volumecontrolled continuous mandatory ventilation (VCCMV) 8.1.
Volumecontrolled intermittent mandatory ventilation (VCIMV) 8.2.
Pressurecontrolled continuous mandatory ventilation (PCCMV) 8.3.
Pressurecontrolled intermittent mandatory ventilation (PCIMV) 8.4.
Pressurecontrolled continuous spontaneous ventilation 8.5.
(PCCSV)
All forms of CSV are either uncontrolled (i.e., the 8.5.1.
ventilator does nothing) or forms of pressure control.
Therefore PCCSV may be abbreviated as CSV.
Targeting Schemes. 9. During inspiration, the control variable can be
manipulated by a variety of feedback control or targeting schemes.
These schemes can be ranked according to complexity and degree
84096_CH05_Chatburn.indd 160 6/17/10 1:32:09 PM
Classifying Modes of Mechanical Ventilation  161
of required operator intervention. Common examples include the
following:
Setpoint control: 9.1. the operator is required to preset all param
eters of the breath (i.e., pressure, volume, flow, and timing)
Dual control: 9.2. the operator presets pressure, volume, flow, and
timing parameters and the ventilator switches between volume
control and pressure control, within a single breath, based on the
preset parameters.
Servo control: 9.3. the ventilator delivers pressure in proportion to
the patientgenerated volume and/or flow according to a preset
model (e.g., the equation of motion). Model parameters are pre
set by the operator.
Adaptive control: 9.4. the ventilator automatically adjusts one or
more breath setpoints based on other operator preset criteria
(e.g., the ventilator adjusts peak inspiratory pressure to achieve
an average preset target tidal volume).
Optimum control: 9.5. the ventilator automatically adjusts one or
more setpoints based a model that attempts to minimize or maxi
mize some other variable(s). Parameters of the model may be
preset by the operator.
Intelligent control: 9.6. the ventilator automatically adjusts one or
more setpoints based on an artificial intelligence program.
Modes of Ventilation. 10. The control variable (i.e., volume or pressure),
the ventilatory pattern, and the targeting scheme are the levels of a
taxonomy for modes of ventilation analogous to the family, genus,
and species taxonomy for animals. For example, BiPAP and Adaptive
Support Ventilation are different modes of the PCIMV ventila
tory pattern in the pressure control family just as lions and tigers are
different species in the genus panther in the family of cats. A mode of
ventilation, therefore, is a complete specification for preset ventilator
patient interaction. A mode description comprises a unique combina
tion of control variable, ventilatory pattern, targeting scheme, and
other relevant operational algorithms. A mode may also be referred to
by a name, such as “pressure support” or “SmartCare.”
Any mode of ventilation can be associated with one and only 10.1.
one ventilatory pattern.
Modes within a particular ventilatory pattern are distinguished 10.2.
by their targeting scheme, the trigger and cycle criteria, and any
84096_CH05_Chatburn.indd 161 6/17/10 1:32:09 PM
162  CHAPTER 5 Mechanical Ventilation
other unique operational algorithm feature. The finer the distinc
tion required, the more levels of criteria that are needed.
Table 510 shows how this system can be used to classify a variety of modes
of ventilation.
Table 5–10 A selection of modes named by manufacturers classified using the tax
onomy built from the 10 aphorisms
Control
Variable
Breath
Sequence
Targeting
Scheme
Example Modes
Volume
Control
CMV
SetPoint Volume Control, VCA/C, CMV, (S)CMV,
Assist/Control
Dual CMV + Pressure Limited
Adaptive Adaptive Flow
IMV
SetPoint SIMV, VCSIMV
Dual SIMV + Pressure Limited
Adaptive AutoMode (VCVS), Mandatory Minute
Volume
Pressure
Control
CMV
SetPoint Pressure Control, PCA/C, AC PCV, HFO,
HFJV
Adaptive Pressure Regulated Volume Control,
VC+A/C, CMV+AutoFlow
IMV
SetPoint Airway Pressure Release Ventilation SIMV
PCV, BiLevel, PiPAP S/T, DuoPAP, PCV+
Adaptive VC + SIMV, V V + SIMV, SIMV + AutoFlow,
Automode (PRVCVS)
Optimal Adaptive Support Ventilation
Pressure
Control
CSV
SetPoint CPAP, Pressure Support
Dual Volume Assured Pressure Support
Servo Proportional Assist Ventilation, Automatic
Tube Compensation
Adaptive Volume Support
Intelligent SmartCare, Adaptive Support Ventilation
VC 5 volume control; PC 5 pressure control; CMV 5 continuous mandatory ventilation; IMV 5 intermittent
mandatory ventilation; CSV 5 continuous spontaneous ventilation.
84096_CH05_Chatburn.indd 162 6/17/10 1:32:09 PM
Mathematical Models of PressureControlled Mechanical Ventilation  163
mAthemAtiCAl moDels of Pressure ■
ControlleD meChAniCAl VentilAtion
Reference: J Appl Physiol 67(3) (1982), 1081–1092.
Glossary
C compliance (L/cm H
2
O)
D inspiratory time fraction (TI/TTOT)
f frequency (breaths/min)
RE expiratory resistance (cm H
2
O ? L
21
? s)
RI inspiratory resistance (cm H
2
O ? L
21
? s)
TE
expiratory time (s)
TI
inspiratory time (s)
TCT total cycle time (s) 5 TI + TE 5 f/60
V
#
E minute ventilation (L/min)
VT
tidal volume
W inspiratory work per breath (J)
W
#
power of breathing; rate of work (J/min)
tI inspiratory time constant (s) 5 C ? RI
tE expiratory time constant (s) 5 C ? RE
PIP peak inspiratory pressure above set PEEP (cm H
2
O)
PA
alveolar pressure above set PEEP (cm H
2
O)
PAW mean airway pressure above set PEEP (cm H
2
O)
PA mean alveolar pressure above set PEEP (cm H
2
O)
PSET preset constant inspiratory pressure above preset PEEP during pres
sure controlled ventilation (cm H
2
O)
PEEP preset positive endexpiratory airway pressure
PEE
endexpiratory alveolar pressure or autoPEEP (cm H
2
O)
Model Assumptions
1. The pressure applied at the airway opening represents the entire pres
sure difference acting on the respiratory system; passive conditions exist
throughout the ventilatory cycle.
2. The pressure applied to the airway opening rises immediately to PSET
during inspiration and falls immediately to PEEP during expiration; a
rectangular pressure–time waveform is assumed.
84096_CH05_Chatburn.indd 163 6/17/10 1:32:09 PM
(+ s :?8GK<I, D\Z_Xe`ZXcM\ek`cXk`fe
3. The units for each variable are those commonly used clinically:
a. Time (seconds, s)
b. Pressure (cm H
2
O)
c. Volume (liters, L)
d. Resistance (cm H
2
O s L
1
)
e. Compliance (L/cm H
2
O)
f. Frequency (breaths/min)
For inspiration, assuming PEE 0
Vt C PSET1 e
tI
PAt PSET1 e
tI
PEEP
V
It ;
PSET
RI
<e
tI
For single expiration, assuming PEE 0
Vt C PSETe
tE
PAt PSETe
tE
PEEP
V
It ;
PSET
RI
<e
tE
General equations, assuming PEE°⁄ 0
VT
PSET C 1 e
TII
1 e
TEE
1 e
TII
e
TEE
VT
PSET C 1 e
60DfR
I
C
F1 e
601DfREC
G
1 e
60DfR
I
C
e
601DfREC
PEE
V
Ee
TEE
f C1 e
TEE
PEEP
VTe
TEE
C1 e
TEE
PEEP
PEE
PSETe
TEE
1 e
TII
1 e
TII
e
TEE
PEEP
DXk_\dXk`ZXcDf[\cjf]Gi\jjli\$:fekifcc\[D\Z_Xe`ZXcM\ek`cXk`fe s (,
PEE
V
EFe
601DfREC
G
f CF1 e
601DfREC
G
PEEP
VTFe
601DfREC
G
CF1 e
601DfREC
G
PEEP
PA TCTC F PSET C TI PSET C VEE I 1 e
TII
VT VEE E 1 e
TEE
G PEEP
where
VEE
VTe
TEE
1 e
TEE
PA =
PSET1 e
TII
1 e
TII
e
TEE
> PEEP
W C PSETPSET PEE 1 e
TII
W
f C PSETPSET PEE 1 e
TII
Intentional Blank 166
84096_CH05_Chatburn.indd 166 6/17/10 1:32:13 PM
CHAPTER
6
CHAPTER
6
Mathematical
Procedures
84096_CH06_Chatburn.indd 167 6/18/10 12:14:24 PM
168  CHAPTER 6 Mathematical Procedures
The multidisciplinary approach to medicine has incorporated a wide variety
of mathematical procedures from the fields of physics, chemistry, and engi
neering. The information presented in this chapter is designed as a selfteach
ing refresher course to be used as a review of basic mathematical procedures.
Some of the more advanced mathematical concepts, including the section on
descriptive statistics, should also help the practitioner to interpret data pre
sented in medical journals and scientific articles.
Fundamental axioms ■
Commutative Axiom
a + b 5 b + a
ab 5 ba
When two or more numbers are added or multiplied together, their order
does not affect the result.
Associative Axiom
(a + b) + c 5 a + (b + c)
(ab)c 5 a(bc)
When three or more numbers are added together, the way they are grouped
or associated makes no difference in the result. The same holds true for mul
tiplication.
Distributive Axiom
a(b + c) 5 ab + ac
A coefficient (multiplier) of a sum may be distributed as a multiplier of each
term.
Order of Precedence
A convention has been established for the order in which numerical opera
tions are performed. This is to prevent confusion when evaluating expres
sions such as 2 3 3
2
, which could be either 18 or 36. The following rules
apply:
84096_CH06_Chatburn.indd 168 6/18/10 12:14:24 PM
Fractions  169
1. If the numerical expression does not contain fences (such as parenthe
ses), then operations are carried out in the following order:
a. Raising numbers to powers or extracting roots of numbers.
b. Multiplication or division.
c. Addition or subtraction.
Example
4 3 5 + 8 ÷ 2 + 6
2
2 216 + 1 5 20 + 4 + 36 – 4 + 1 5 57
2. If the numerical expression does contain fences, then follow the pro
cedure in Rule 1, starting with the innermost set of parentheses. The
sequence is round fences (parentheses), square fences [brackets], double
fences {braces}. Once the fences have been eliminated, the expression
can be evaluated following Rule 1.
Example
2 + 4 3 {3 3 2 – [5 3 4 + (2 3 3 – 4 ÷ 1) – 20] + 12}
5 2 + 4 3 {3 3 2 – [5 3 4 + (6 – 4) – 20] + 12}
5 2 + 4 3 {3 3 2 – [5 3 4 + 2 – 20] + 12}
5 2 + 4 3 {3 3 2 – [20 + 2 – 20] + 12}
5 2 + 4 3 {3 3 2 – 2 + 12}
5 2 + 4 3 {6 – 2 + 12}
5 2 + 4 3 16
2 + 64 5 66
Fractions ■
When a number is expressed as a fraction (e.g.,
3
5
), the number above the line
(3) is called the numerator and the number below the line (5) the denomi
nator.
Multiplication Property of Fractions
a 3 c
b 3 c
5
a
b
1c 2 02
The numerator and denominator of a fraction may be multiplied or divided
by the same nonzero number to produce a fraction of equal value.
84096_CH06_Chatburn.indd 169 6/18/10 12:14:24 PM
170  CHAPTER 6 Mathematical Procedures
Example
Simplify (reduce) the fraction
9
12
Solution
1. Find the largest integer that will evenly
divide both the numerator and denomi
nator.
The largest whole number is 3.
2. Divide both the numerator and denomi
nator by that number.
9
12
5 a
9
3
b 4 a
12
3
b 5
3
4
Multiplication of Fractions
a
b
3
c
d
5
ac
bd
Example
7
9
3
3
4
5 ?
Solution
1. Multiply the numerators. 7 3 3 5 21
2. Multiply the denominators. 9 3 4 5 36
3. Simplify the resulting fraction if possible. 7
9
3
3
4
5
21
36
5
7
12
Division of Fractions
a
b
4
c
d
5
a
b
3
d
c
5
ad
bc
84096_CH06_Chatburn.indd 170 6/18/10 12:14:25 PM
Fractions  171
Example
Find the quotient:
5
8
4
2
3
Solution
1. Invert the divisor.
Change
2
3
to
3
2
2. Multiply the dividend by the inverted divisor. 5
8
3
3
2
5
15
16
3. Simplify if possible.
Addition and Subtraction of Fractions with the Same
Denominator
a
b
1
c
b
5
1a 1 c2
b
a
b
2
c
b
5
1a 2 c2
b
Example
5
32
1
13
32
2
3
32
5 ?
Solution
1. Combine numerators. 5 + 13 2 3 5 15
2. Write the resultant fraction with the new numerator
and the same denominator.
15
32
3. Simplify if possible.
84096_CH06_Chatburn.indd 171 6/18/10 12:14:25 PM
172  CHAPTER 6 Mathematical Procedures
Addition and Subtraction of Fractions with Different
Denominators
To add or subtract fractions that do not have the same denominator, it is first
necessary to express them as fractions having the same denominators. To
find a common denominator, find an integer that is evenly divisible by each
denominator. The smallest or least common denominator (LCD) is the most
convenient.
Example
5
4
1
7
18
5 ?
Solution
1. First find the LCD as follows:
a. Express each denominator as the prod
uct of primes (integers greater than 1
that are evenly divisible by only them
selves and 1).
a. 4 5 2 3 2 5 2
2
18 5 2 3 3 3 3
5 2 3 3
2
b. Note the greatest power to which an
integer occurs in any denominator.
b. 2
2
is the greatest power of 2 in
either denominator, 3
2
is the
greatest power of 3 in either
denominator.
c. The product of the integers noted in
part b is the LCD.
c. 2
2
3 3
2
5 36
2. Write fractions as equivalent fractions with
denominators equal to the LCD.
5
4
3
9
9
5
45
36
7
18
3
2
2
5
14
36
3. Combine the numerators and use the LCD
as the denominator.
45
36
+
14
36
5
59
36
5 1.64
4. Simplify if possible.
84096_CH06_Chatburn.indd 172 6/18/10 12:14:26 PM
Ratios, Proportions, and Unit Conversion  173
ratios, ProPortions, and unit conversion ■
The ratio of two numbers may be written as follows:
a/b 5 a:b
Two equivalent ratios form a proportion.
a/b 5 c/d
a:b 5 c:d
a:b :: c:d
Regardless of how the above proportions are expressed, they are read “a is to
b as c is to d.”
Ratios provide a convenient method for converting units. To change the units
of a quantity, multiply by ratios whose values are equal to 1 (which does not
change the value of the quantity). Select the dimensions of the ratios such
that the unit to be changed occurs as a factor of the numerator or as a factor
of the denominator. Thus, when the quantity is multiplied by the ratio, the
unit is canceled and replaced by an equivalent unit and quantity.
Example
Convert 2 kilometers/hour to feet/second.
Solution
1. Write an equation expressing the problem. 2 km/hr 5 x ft/s
2. Multiply the known quantity by ratios whose value is
equal to 1, such that the desired unit remains after
canceling pairs of equal dimensions that appear in
both the numerator and the denominator.
1 km 5 1,000 m
1 m 5 3.281 ft
1 hr 5 60 min
1 min 5 60 s
2 km
hr
3
1,000 m
1 km
3
3.3 ft
1 m
3
1 hr
60 min
3
1 min
60 s
5
6,600 ft
3,600 s
5
1.8 ft
s
84096_CH06_Chatburn.indd 173 6/18/10 12:14:26 PM
174  CHAPTER 6 Mathematical Procedures
exPonents ■
When a product is the result of multiplying a factor by itself several times,
it is convenient to use a shorthand notation that shows the number used as a
factor (a) and the number of factors (n) in the product. In general, such num
bers are expressed in the form a
n
, where a is the base and n the exponent.
The rules for these numbers are shown in Table 6–7.
Table 6–7 Rules for Exponents
Rule Example
a
n
? a
m
5 a
n1m
x
2
? x
3
5 x
5
a
n
÷ a
m
5 a
n2m
z
7
÷ z
5
5 z
2
(ab)
n
5 a
n
b
n
(2wy)
2
5 4w
2
y
2
a
0
5 1, (a ? 0) 9x
0
5 9
a
1
5 a 3x
1
5 3x
a
2n
5 1/a
n
x
22
5 1/x
2
a
1/n
5 2
n
a y
1/3
5 2
3
y
a
m/n
5 2
n
a
m
z
2/3
5 2
3
z
2
(a
m
)
n
5 a
mn
(w
2
)
3
5 w
6
scientiFic notation ■
A number expressed as a multiple of a power of 10, such as 3.02 3 10
5
, is
said to be written in scientific notation. Numbers written in this way have
two parts: a number between 1 and 10 called the coefficient, multiplied by a
power of 10 called the exponent. This notation has three distinct advantages:
a. It simplifies the expression of very large or very small numbers that
would otherwise require many zeros. For example, 681,000,000 5
6.81 3 10
8
and 0.000026 5 2.6 3 10
25
.
b. Scientific notation clarifies the number of significant figures in a
large number. For example, if the radius of the earth is written as
6,378,000 m, it is not clear whether any of the zeros after the 8 is
significant. However, when the same number is written as 6.378 3
10
6
m, it is understood that only the first four digits are significant.
c. Calculations that involve very large or very small numbers are great
ly simplified using scientific notation.
84096_CH06_Chatburn.indd 174 6/18/10 12:14:26 PM
Scientific Notation  175
Addition and Subtraction
Example
6.18 3 10
3
+ 1.9 3 10
2
– 5.0 3 10
1
Solution
1. Convert all numbers to the same power
of 10 as the number with the highest
exponent.
6.18 3 10
3
5 6.18 3 10
3
1.9 3 10
2
5 0.19 3 10
3
5.0 3 10
1
5 0.05 3 10
3
2. Add or subtract the coefficients and
retain the same exponent in the answer.
6.18 3 10
3
1 0.19 3 10
3
2 0.05 3 10
3
6.32 3 10
3
Multiplication and Division
Example
(4 3 10
23
)(2 3 10
14
)
Solution
1. Multiply (or divide) the coefficients. (4 3 10
23
)(2 3 10
14
)
5 8(10
23
3 10
14
)
2. Combine the powers of 10 using the rules for expo
nents.
8(10
23
3 10
14
)
5 8 3 10
23 + 14
5 8 3 10
37
Powers and Roots
Example
(4 3 10
5
)
2
Solution
1. Raise the coefficient to the indicated power. (4 3 10
5
)
2
5 (4
2
)(10
5
)
2
5 16(10
5
)
2
2. Multiply the exponent by the indicated power. 16(10
5
)
2
5 16(10
5 3 2
)
5 16 3 10
10
5 1.6 3 10
11
84096_CH06_Chatburn.indd 175 6/18/10 12:14:26 PM
176  CHAPTER 6 Mathematical Procedures
signiFicant Figures ■
By convention, the number of digits used to express a measured number
roughly indicates the error. For example, if a measurement is reported as
35.2 cm, one would assume that the true length was between 35.15 and 35.24
cm (i.e., the error is about 0.05 cm). The last digit (2) in the reported mea
surement is uncertain, although one can reliably state that it is either 1 or 2.
The digit to the right of 2, however, can be any number (5, 6, 7, 8, 9, 0, 1,
2, 3, 4). If the measurement is reported as 35.20 cm, it would indicate that
the error is even less (0.005 cm). The number of reliably known digits in a
measurement is the number of significant figures. Thus, the number 35.2 cm
has three significant figures, and the number 35.20 cm has four. The number
of significant figures is independent of the decimal point. The numbers 35.2
cm and 0.352 m are the same quantities, both having three significant figures
and expressing the same degree of accuracy. The use of significant figures to
indicate the accuracy of a result is not as precise as giving the actual error,
but is sufficient for most purposes.
Zeros as Significant Figures
Final zeros to the right of the decimal point that are used to indicate accuracy
are significant:
179.0 4 significant figures
28.600 5 significant figures
0.30 2 significant figures
For numbers less than one, zeros between the decimal point and the first digit
are not significant:
0.09 1 significant figure
0.00010 2 significant figures
Zeros between digits are significant:
10.5 3 significant figures
0.8070 4 significant figures
6000.01 6 significant figures
84096_CH06_Chatburn.indd 176 6/18/10 12:14:26 PM
Significant Figures  177
If a number is written with no decimal point, the final zeros may or may not
be significant. For instance, the distance between Earth and the sun might
be written as 92,900,000 miles, although the accuracy may be only ±5000
miles. This would make only the first zero after the 9 significant. On the
other hand, a value of 50 mL measured with a graduated cylinder would be
expected to have two significant figures owing to the greater accuracy of the
measurement. To avoid ambiguity, numbers are often written as powers of
10 (scientific notation), making all digits significant. Using this convention,
92,900,000 would be written 9.290 3 10
7
, indicating that there are four sig
nificant figures.
Calculations Using Significant Figures
The least precise measurement used in a calculation determines the number
of significant figures in the answer. Thus, 73.5 + 0.418 5 73.9 rather than
73.918, since the least precise number (73.5) is accurate to only one decimal
place. Similarly, 0.394 – 0.3862 5 0.008, with only one significant figure.
For multiplication or division, the rule of thumb is: The product or quotient
has the same number of significant figures as the term with the fewest sig
nificant figures. As an example, in 28.08 3 4.6/79.4 5 1.6268, the term with
the fewest significant figures is 4.6. Since this number has at most two sig
nificant figures, the result should be rounded off to 1.6.
Rounding Off
The results of mathematical computations are often rounded off to specific
numbers of significant figures. This is done so that one does not infer an
accuracy in the result that was not present in the measurements. The fol
lowing rules are universally accepted and will ensure biasfree reporting of
results (the number of significant figures desired should be determined first).
1. If the final digits of the number are 1, 2, 3, or 4, they are rounded down
(dropped) and the preceding figure is retained unaltered.
2. If the final digits are 6, 7, 8, or 9, they are rounded up (i.e., they are
dropped and the preceding figure is increased by one).
3. If the digit to be dropped is a 5, it is rounded down if the preceding
figure is even and rounded up if the preceding figure is odd. Thus, 2.45
and 6.15 are rounded off to 2.4 and 6.2, respectively.
84096_CH06_Chatburn.indd 177 6/18/10 12:14:27 PM
178  CHAPTER 6 Mathematical Procedures
Functions ■
A function is a particular type of relation between groups of numbers. The
uniqueness of a function is that each member of one group is associated with
exactly one member of another group. In general, let the variable x stand for
the values of one group of numbers and the variable y stand for the values
of another group. If each value of x is associated with a unique value of y,
then this relation is a function. Specifically, y is said to be a function of x and
is denoted y 5 f(x). With this notation, x is called the independent variable
and y the dependent variable. A function may be represented graphically by
using a twodimensional coordinate (Cartesian) plane formed by two perpen
dicular axes intersecting each other at a point with coordinates designated
as x 5 0, y 5 0 (Fig. 6–1). The vertical axis denotes values of y and the
horizontal axis values of x. The function is plotted as a series of points whose
coordinates are the values of x with their corresponding values of y as deter
mined by the function.
Figure 6–1 Graphic representation of the function y = ƒ(x), where ƒ(x)= 0.3x + 1.
y = f (x)
30 28 26 24 22 20 18 16 14 12 10 8 6 4 2 0
Y
–
a
x
i
s
X – axis
10
9
8
7
6
5
4
3
2
1
Linear Functions
One of the simplest functions is expressed by the formula
y 5 ax
84096_CH06_Chatburn.indd 178 6/18/10 12:14:27 PM
Functions  179
where
y and x are variables
a is a constant
The constant a is sometimes referred to as the constant of proportionality
and y is said to be directly proportional to x (if y is expressed as y 5 a/x, y
is said to be inversely proportional to x and the function is no longer linear).
The graph of the equation y 5 ax is a straight line. The constant a is the
slope of the line.
General Linear Equation
y 5 ax + b
where
y 5 dependent variable
a 5 slope
x 5 independent variable
b 5 yintercept (the value of y at which the graph of the equation crosses
the yaxis)
Solving Linear Equations
To solve a linear equation,
1. Combine similar terms.
2. Use inverse operations to undo remaining additions and subtractions
(i.e., add or subtract the same quantities to both sides of the equation).
Get all terms with the unknown variable on one side of the equation.
3. If the equation involves fractions, multiply both sides by the least com
mon denominator.
4. If there are multiplications or divisions indicated in the variable term,
use inverse operations to find the value of the variable.
5. Check the result by substituting the value into the original equation.
84096_CH06_Chatburn.indd 179 6/18/10 12:14:27 PM
180  CHAPTER 6 Mathematical Procedures
Examples
1.
8 1 10x 2 40 5 3x 1 7 1 2x 1
2x
3
10x 2 32 5 5x 1
2x
3
1 7
2.
10x 2 32 1 32 5 5x 1
2x
3
1 7 1 32
10x 5 5x 1
2x
3
1 39
10x 2 5x 2
2x
3
5 39
5x 2
2x
3
5 39
3. 3 a5x 2
2x
3
b 5 3(39)
15x 2 2x 5 117
4. 13x 5 117
13x
13
5
117x
13
x 5 9
5. 8 1 10(9) 2 40 5 3(9) 1 7 1 2(9) 1
2192
3
8 1 90 2 40 5 27 1 7 1 18 1 6
58 5 58
Quadratic eQuations ■
A function of the form y 5 ax
2
is called a quadratic function. It is some
times expressed in the more general form
y 5 ax
2
+ bx + c
where
a, b, and c are constants
84096_CH06_Chatburn.indd 180 6/18/10 12:14:28 PM
Quadratic Equations  181
The graph of this equation is a parabola. Frequently, it is of interest to know
where the parabola intersects the xaxis. The value of y at any point on the
xaxis is zero. Therefore, to find the values of x where the graph intersects
the xaxis, the quadratic equation is expressed in standard form:
ax
2
+ bx + c 5 0
with a ? 0.
The solution of any quadratic equation expressed in standard form may be
found using the quadratic formula:
x 5
2b ; 2b
2
2 4ac
2a
where
a, b, and c are the coefficients in the quadratic equation
Example
Solve 3x
2
+ 7 5 10x
Solution
1. Write the equation in standard
form.
3x
2
2 10x + 7 5 0
2. Note the coefficients a, b, and c. a 5 3, b 5 210, c 5 7
3. Substitute these values in the
quadratic formula:
x 5
2b ; 2b
2
2 4ac
2a
x 5
212102 ; 212102
2
2 4132 172
2132
4. Simplify.
x 5
10 ; 2100 2 84
6
5
10 ; 216
6
5 2.33 or 1
84096_CH06_Chatburn.indd 181 6/18/10 12:14:28 PM
182  CHAPTER 6 Mathematical Procedures
logarithms ■
The logarithm of a number (N) is the exponent (x) to which the base (a)
must be raised to produce N. Thus, if a
x
5 N then log
a
N 5 x for a . 0
and a ? 0. For example, log
2
8 5 3 (read: the log to the base 2 equals 3)
because 2
3
5 8. Logarithms are written as numbers with two parts: an integer,
called the characteristic, and a decimal, called the mantissa (e.g., log
10
86 5
1.9345).
Common Logarithms
Common logarithms are those that have the base 10. In this book, the base
number will be omitted with the assumption that log means log
10
. Table 6–1
shows the general rules of common logarithms.
x log x
10
0
5 1 log 1 5 0
10
1
5 10 log 10 5 1
10
2
5 100 log 100 5 2
Table 6–1 Rules of Common Logarithms
Rule Example
1. log ab 5 log a + log b x 5 (746)(384)
(a . 0, b . 0) log x 5 log 746 + log 384
log 746 5 2.8727
log 384 5 2.5843
log x 5 5.4570
x 5 286,400
2. log 1/a 5 2log a x 5 1/273
(a . 0) log x 5 2log 273
5 22.4362
5 3.5638
x 5 0.003663
84096_CH06_Chatburn.indd 182 6/18/10 12:14:28 PM
Logarithms  183
Table 6–1 Rules of Common Logarithms (continued)
Rule Example
3. log a/b 5 log a 2 log b x 5 478/21
(a . 0, b . 0) log x 5 log 478 2 log 21
log 478 5 2.6794
log 21 5 1.3222
log x 5 1.3572
x 5 22.76
4. log a
n
5 n log a
x 5 2
3
374
(a . 0, n is a real number) 5 (374)
1/3
log x 5 1/3 log 374
log 374 5 2.5729
log x 5 1/3(2.5729)
5 0.8576
x 5 7.204
The Characteristic
The integer or characteristic of the logarithm of a number is determined by
the position of the decimal point in the number. The characteristic of a num
ber can easily be found by expressing the number in scientific notation. Once
in this form, the exponent is used as the characteristic.
Examples
Number Characteristic
3025 5 3.025 3 10
3
3
302.5 5 3.025 3 10
2
2
30.25 5 3.025 3 10
1
1
3.025 5 3.025 3 10
0
0
0.3025 5 3.025 3 10
21
21
Note: The characteristics of logarithms of numbers less than 1 can be written
in several ways. Thus, log 0.0361 5 log 3.61 3 10
22
5 2.5575 (not –2.5575)
or 8.5575 – 10. Written as a negative number (as with handheld calculators)
log 0.0361 5 –1.4425.
84096_CH06_Chatburn.indd 183 6/18/10 12:14:28 PM
184  CHAPTER 6 Mathematical Procedures
The Mantissa
The mantissa is the decimal part of the logarithm of a number. The mantissa
of a series of digits is the same regardless of the position of the decimal
point. Thus, the logarithms of 1.7, 17, and 170 all have the same mantissa,
which is 0.230.
Antilogarithms
The number having a given logarithm is called the antilogarithm (antilog).
The logarithm of 125 is approximately 2.0969. Therefore, the antilog of
2.0969 is 10
2.0969
, which is approximately 125.
Antilogs of Negative Logarithms
Using a calculator, negative logarithms can be solved simply by using the 10
x
key. For example, the antilog of –2 is 10
22
5 0.01. However, log and antilog
tables in reference books are used with positive mantissas only. Therefore, a
negative logarithm must be changed to a log with a positive mantissa to find
its antilog. This change of form is accomplished by first adding and then sub
tracting 1, which does not alter the original value of the logarithm.
Example
Find antilog 21.6415
Solution
1. Write the log as a negative character
istic minus the mantissa.
21.6415 5 21 2 0.6415
2. Subtract 1 from the characteristic and
add 1 to the mantissa.
21 2 0.6415 5 21 2 1 2 0.6415
+ 1 5 22 1 0.3585
3. Express the result as a log having a
negative characteristic and a positive
mantissa.
22 1 0.3585 5 2.3585
4. Use the tables to find the antilog.
antilog 21.6415 5 antilog 2.3585
5 0.02283
84096_CH06_Chatburn.indd 184 6/18/10 12:14:28 PM
Logarithms  185
Natural Logarithms
When a logarithmic function must be differentiated or integrated, it is con
venient to rewrite the function with the number e as a base. The number e is
approximately equal to 2.71828. Logarithms which have the base e are called
natural logarithms and are denoted by ln (read: “ellen”).
If e
x
5 N, then log
e
N 5 ln N 5 x
Any number of the form a
x
may be rewritten with e as the base:
a
x
5 e
x ln a
Note: e
x
is sometimes written as exp(x).
The same rules apply to natural logarithms that apply to common logarithms.
See Table 6–2.
Table 6–2 Rules of Natural Logarithms
1. ln ab 5 ln a + ln b (a . 0, b . 0)
2. ln 1/a 5 2 ln a (a . 0)
3. ln a/b 5 ln a 2 ln b (a . 0, b . 0)
4. ln a
x
5 x ln a (a . 0, x is a real number)
5. ln e 5 1
6. ln e
x
5 x 5 e
ln x
7. a
x
5 e
x ln x
(a . 0)
8. ln x 5 (ln 10)(log x) 5 2.3026(log x) (x . 0)
Change of Base
Logarithms to one base can easily be changed to logarithms of another base
using the following equation.
log
a
x 5
log
b
x
log
b
a
84096_CH06_Chatburn.indd 185 6/18/10 12:14:28 PM
186  CHAPTER 6 Mathematical Procedures
Example
log
10
x 5
log
e
x
log
e
10
5
ln x
ln 10
6 ln x 5 2.302585 log
10
x
trigonometry ■
Systems of Angular Measure
Degree
The degree is defined as 1/360 of a complete revolution.
1 revolution 5 3608
1 right angle 5 908
1 degree 5 60 minutes (609)
1 minute 5 60 seconds (600)
Radian
The radian is defined as the angle subtended at the center of a circle by an
arc whose length is equal to the radius of the circle. In general, an angle u in
radians is given by
u 5
s
r
where
s 5 arc length
r 5 radius
Relationship Between Degrees and Radians
1 revolution 5 2p radians
p 5 3.14159 . . .
1 degree 5 2p/360 radians 5 0.0174.53 radian
308 5 p/6 radians
458 5 p/4 radians
608 5 p/3 radians
908 5 p/2 radians
1808 5 p radians
84096_CH06_Chatburn.indd 186 6/18/10 12:14:29 PM
Trigonometry  187
Trigonometric Functions
In trigonometry, an angle is considered positive if it is generated by a coun
terclockwise rotation from standard position, and negative if it is generated
by a clockwise rotation (Fig. 6–2). The trigonometric functions of a positive
acute angle u can be defined as ratios of the sides of a right triangle:
sine of u 5 sin u 5 y/r
cosine of u 5 cos u 5 x/r
tangent of u 5 tan u 5 y/x
cotangent of u 5 cot u 5 x/y
secant of u 5 sec u 5 r/x
cosecant of u 5 csc u 5 r/y
These functions can also be expressed in terms of sine and cosine alone:
tan u 5 sin u/cos u
cot u 5 cos u/sin u
sec u 5 1/cos u
csc u 5 1/sin u
Figure 6–2 An angle is generated by rotating a ray (or halfline) about the origin of a
circle. The angle is positive if it is generated by a counterclockwise rotation from the
xaxis and negative for a clockwise rotation.
Y
X
x
r
y
Positive
Negative
θ
84096_CH06_Chatburn.indd 187 6/18/10 12:14:29 PM
188  CHAPTER 6 Mathematical Procedures
Basic Trigonometric Identities
sin
2
u + cos
2
u 5 1
sec
2
u 5 1 + tan
2
u
Probability ■
The probability of an event A is denoted p(A). It is defined as follows: If
an event can occur in p number of ways and can fail to occur in q number
of ways, then the probability of the event occurring is p/(p + q). The odds in
favor of an event occurring are p to q.
Addition Rule
If A and B are any events, then
p(A or B) 5 p(A) + p(B) – p(A and B)
Example
The probability of drawing either a king or a black card from a deck of 52 playing
cards is
p(king or black card) 5 p(king) 1 p(black card) 2 p(king also black)
5 4/52 1 26/52 2 2/52
5 7/13
Note: If events A and B cannot occur at the same time, they are said to be
mutually exclusive, and the addition rule can be simplifed to
p(A or B) 5 p(A) + p(B)
Multiplication Rule
If A and B are any events, then
p(A and B) 5 p(AB) 3 p(B)
where
p(AB) 5 the probability of event A given that event B has occurred
84096_CH06_Chatburn.indd 188 6/18/10 12:14:29 PM
Probability  189
Example
Two cards are drawn from a deck of 52 playing cards. The first card is not replaced
before the second card is drawn. The probability that both cards are aces is given
by
p(both aces) 5 p(2nd card is acelst card is ace) 3 p(lst card is ace)
5 3/51 3 4/52
5 1/221
Notice that if the first card is an ace, p(AB) 5 3/51, since there are only 3
aces left of 51 remaining cards.
Note: If the occurrence of event B is in no way affected by the occurrence or
nonoccurrence of event A (e.g., if the first card drawn was replaced before
the second card was drawn in the preceding example), the two events are
said to be independent, and the multiplication rule can be simplified to
p(A and B) 5 p(A) 3 p(B)
Factorial Notation(!)
A number such as n! (read: n factorial) is defined by the equation
n! 5 n(n – 1)(n – 2) . . . (1)
where
0! 5 1 and n is a positive integer
Example
5! 5 5 3 4 3 3 3 2 3 1 5 120
Permutations
Each arrangement of all or a part of a set of objects is called a permutation.
The total number of permutations of n different objects taken r at a time is
n
P
r
5
n!
1n 2 r2!
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190  CHAPTER 6 Mathematical Procedures
Combinations
Each of the groups that can be made by taking all or a part of a set of objects,
without regard to the order of arrangement of the objects in a group, is called
a combination. The total number of combinations of n different objects
taken r at a time is
n
C
r
5
n!
r!1n 2 r2!
statistical Procedures ■
Mode
In a distribution, the numerical value that occurs most frequently is called
the mode. While the mode is a quick and easy method of determining central
tendency or “average,” it is unstable (fluctuates with sample selection) and
therefore has limited use.
Median
The median is the point on a numerical scale that has as many items above
it as below it. The median is an index of “average” position in a distribution
of numbers. It is insensitive to extreme values and is therefore the preferred
index of central tendency when the distribution is skewed and one is inter
ested in a “typical” value.
Mean (X, m)
The mean is the index of central tendency that is most often referred to as an
average. It is more stable than the mode or median.
X 5
SX
n
where
S 5 the sum of
X 5 individual raw score
n 5 number of scores
84096_CH06_Chatburn.indd 190 6/18/10 12:14:29 PM
Statistical Procedures  191
Note: X denotes the mean of a sample, while m represents the mean of a
population.
Standard Deviation (s, s)
The standard deviation is the most widely used measure of variability (the
extent to which scores deviate from each other). The equations are
s 5
Å
Sx
2
n
(used when finding the standard deviation of a population,
with the sample taken to be population)
s 5
Å
Sx
2
n 2 1
(used to estimate the standard deviation of a population
from the sample data extracted from that population)
where
S 5 the sum of
x 5 deviation score (the difference between an individual score and the
mean)
n 5 number of scores
Correlation Coefficient (Pearson r)
The correlation coefficient is a measure of the degree of association
between two variables. The values of a correlation coefficient range from
–1.0 (perfect negative or inverse relationship) through 0 (no relationship) to
+1.0 (perfect positive or direct relationship). The higher the absolute value
of the coefficient, the stronger the relationship. It should be noted that a high
degree of correlation does not necessarily mean that one variable causes the
other. The most commonly used correlation index, the Pearson r, can be
computed as
r 5
Sxy
ns
x
s
y
where
r 5 the correlation coefficient for variables X and Y
x 5 deviation score for X (the difference between an individual score
and the mean)
84096_CH06_Chatburn.indd 191 6/18/10 12:14:29 PM
192  CHAPTER 6 Mathematical Procedures
y 5 deviation score for Y
Sxy 5 sum of the products of each pair of deviation scores
n 5 number of Xvalues paired with a Yvalue
s
x
5 standard deviation of X scores
s
y
5 standard deviation of Y scores
Linear Regression (Method of Least Squares)
Once a correlation has been found between two variables, it is often useful
to find an equation relating them such that one variable (X) can be used to
predict the second (Y). The higher the correlation between the two variables,
the more accurate the prediction. The basic linear regression equation is
a formula for making predictions about the numerical value of one variable
based on the scores of another variable:
Y9 5 a + bX
where
Y9 5 a predicted value for Y
a 5Y 2 bX
b 5 Sxy/Sx
2
in which
a 5 intercept constant
b 5 regression coefficient
Y 5 mean of variable Y
X 5 mean of variable X
x 5 deviation score for X (the difference between an individual score and
the mean)
y 5 deviation score for Y
The graph of the linear regression equation is a straight line that “best fits”
the data.
84096_CH06_Chatburn.indd 192 6/18/10 12:14:29 PM
Statistical Procedures  193
Normal Distribution Curve
The normal distribution curve is a symmetric, bellshaped curve illustrating
the ideal or equal distribution of continuously variable values about a popula
tion mean (see Figure 6–3). A standard normal distribution has a mean of
zero and a standard deviation of one.
Figure 63 Standard deviations (s) in a normal curve.
μ σ
68%
95%
99.7%
–3 σ +3 σ –2 σ +2 σ – σ +
Percentile Rank
The percentile rank of a score essentially gives the percentage of the dis
tribution that is below that score. The word percentile is often used to refer
directly to a score in a distribution. Thus, a score with a percentile rank of 60
would be in the 60th percentile.
percentile rank of X 5
B 1 1>2 E
n
3 100
where
B 5 the number of scores below the given score X
E 5 the number of scores equal to the given score X
n 5 the total number of scores
84096_CH06_Chatburn.indd 193 6/18/10 12:14:30 PM
194  CHAPTER 6 Mathematical Procedures
Definitions of Common Statistical Terms
Alpha (a, level of significance). The preselected level of probability that
leads to rejection of the null hypothesis. It is the probability of incorrectly
rejecting the null hypothesis (Type I error).
Beta (b). The probability of incorrectly accepting the null hypothesis (Type
II error).
Parameter. A variable describing some characteristic of a population.
Population. An entire collection of objects as defined by a set of criteria.
Power. The power of a statistical test is the probability of correctly rejecting
the null hypothesis. Numerically, power is equal to 1 – b.
P value. Given a test procedure and the computed value of the test statistic,
the probable value or P value of the test is the smallest value of a that
results in the rejection of the null hypothesis. Stated differently, it is the
probability of an observed statistical value being equal to or greater than
a given value. For example, the probability of observing a sample mean
that is equal to or greater than two standard deviations away from the pro
posed population mean is 0.046. Thus, the smallest value of a that results
in rejection of the null hypothesis (i.e., that the sample came from a popu
lation whose mean value was the proposed value) is 0.046, hence the P
value of the observed statistic is 0.046.
Research hypothesis. A statement about the parameters of a population.
A “null hypothesis” usually states that there is no difference between
or among two or more populations for a given parameter. An “alternate
hypothesis” usually states that there is a difference between or among two
or more populations for a given parameter.
Sample. A subset of a population.
Statistic. A variable describing some characteristic of a sample and used to
infer the same characteristic of the corresponding population.
Type I error. Rejecting the null hypothesis on the basis of a statistical test
when it is actually true.
Type II error. Accepting the null hypothesis on the basis of a statistical test
when it is actually false.
Universe. The group of experimental units from which a sample is selected.
Variable. A numerical quantity that can take on different values.
84096_CH06_Chatburn.indd 194 6/18/10 12:14:30 PM
195
Reality
S
t
a
t
i
s
t
i
c
a
l
T
e
s
t
R
e
s
u
l
t
Null hypothesis
is true
Correct
decision
D
o
n
o
t
r
e
j
e
c
t
n
u
l
l
h
y
p
o
t
h
e
s
i
s
(
n
o
n

s
i
g
n
i
f
i
c
a
n
t
r
e
s
u
l
t
)
R
e
j
e
c
t
n
u
l
l
h
y
p
o
t
h
e
s
i
s
(
s
i
g
n
i
f
i
c
a
n
t
r
e
s
u
l
t
)
Type II
error
Null hypothesis
is false
probability = 1 – α probability = β
Type I
error
probability = α
Correct
decision
probability = 1 – β
Figure 6–4 Definitions and probabilities of Type I and Type II errors.
Condition of Interest
T
e
s
t
R
e
s
u
l
t
Present Absent
True
Positive
False
Positive
False
Negative
True
Negative
P
o
s
i
t
i
v
e
N
e
g
a
t
i
v
e
a b
c
Sensitivity:
d
a
a+c
Specificity:
d
b+d
False negative rate:
c
c+d
False positive rate:
b
a+b
Positive predictive value:
a
a+b
Negative predictive value:
d
c+d
Figure 6–5 Definitions of sensitivity, specificity, and related indices.
84096_CH06_Chatburn.indd 195 6/18/10 12:14:30 PM
196  CHAPTER 6 Mathematical Procedures
Sensitivity. The probability that a test will be positive when the condition of
interest (e.g., disease) is present.
Specificity. The probability that a test will be negative when the condition of
interest (e.g., disease) is not present.
Truepositive rate. Equivalent to sensitivity.
Falsenegative rate. The falsenegatives as a percentage of all negative
results.
Truenegative rate. Equivalent to specificity.
Falsepositive rate. The falsepositives as a percentage of all positive results.
Positive predictive value. The probability that the condition of interest (e.g.,
disease) is present when the test is positive.
Negative predictive value. The probability that the condition interest (e.g.,
disease) is not present when the test is negative.
mathematical signs and symbols ■
Table 6–3
5 Equals
< Equals approximately
? Is not equal to
; Is identical to, is defined as
. Is greater than (@ is much greater than)
, Is less than (! is much less than)
$ Is greater than or equal to (or is no less than)
# Is less than or equal to (or is no more than)
;
Plus or minus ( 24 5 ; 2)
r
Is proportional to
S The sum of; Sa
K
means a
1
+ a
2
+ . . . + a
n
x The average value of x
Dx The change in x
x
#
The derivative of x with respect to time
P Product of; Pa
K
means a
1
a
2
. . . a
n
84096_CH06_Chatburn.indd 196 6/18/10 12:14:30 PM
Random Numbers  197
the greek alPhabet ■
Table 6–4
Alpha A a Nu N n
Beta B b Xi J j
Gamma G g Omicron O o
Delta D d Pi P p
Epsilon E e Rho R r
Zeta Z z Sigma S s
Eta H h Tau T t
Theta Q u Upsilon Y y
Iota I i Phi F w
Kappa K k Chi X x
Lambda L l Psi C c
Mu M m Omega V v
random numbers ■
A table of random numbers (Table 6–5) can be used to select a random
sample of N items from a universe of M items using the following procedure:
Table 6–5 Random Numbers
10480 15011 01536 02011 81647 91646
22368 46573 25595 85393 30995 89189
24130 48360 22527 97265 76393 64809
42167 93093 06243 61680 07856 16376
37570 39975 81837 16656 06121 91782
77921 06907 11008 42751 27756 53498
99562 72905 56420 69994 98872 31016
96301 91977 05463 07972 18876 20922
89579 14342 63661 10281 17453 18103
85475 36857 43342 53988 53060 59533
(continued)
84096_CH06_Chatburn.indd 197 6/18/10 12:14:30 PM
198  CHAPTER 6 Mathematical Procedures
Table 6–5 Random Numbers (continued)
28918 69578 88231 33276 70997 79936
63553 40961 48235 03427 49626 69445
09429 93969 52636 92737 88974 33488
10365 61129 87529 85689 48237 52267
07119 97336 71048 08178 77233 13916
1. Create an arbitrary procedure for selecting entries from the table. For
example, use the entries from the first line of each column.
2. Assign numbers to each of the items in the universe from 1 to M. Thus,
if M 5 250, the items would be numbered from 001 to 250 such that
each item is associated with a threedigit number.
3. Decide on an arbitrary scheme for selecting digits from each entry in the
table selected according to step 1. That is, each entry has five digits and
for this example we need only three. Thus, we might decide to use the
first, third, and fifth digits in the entry to create the required threedigit
number corresponding to an item in the universe.
4. If the number formed in step 3 is #M, then the correspondingly des
ignated item (from step 2) in the universe is selected for the random
sample of N items. For example, if the first selection was the first entry
in the first column of Table 6–5, 10480, the first, third, and last digits
would yield the number 140. Thus, item number 140 of the universe
of items would be the first picked for the sample. If a number .M is
formed in step 3 or is a repeated number of one already chosen, it is
skipped and the next desirable number is taken. This process is contin
ued until the random sample of N items is selected.
A widely used equation for generating random numbers is
x
n11
5 FRAC (p + x
n
)
5
The equation requires a seed number, x
n
, which can be varied between 0 and
1 to give many random number sequences. The procedure for using the equa
tion is as follows:
1. Select a number between 0 and 1 and add it to the value of p.
2. Raise the result to the fifth power.
3. Take the fraction portion (FRAC, the numbers to the right of the deci
mal point) as the random number.
84096_CH06_Chatburn.indd 198 6/18/10 12:14:31 PM
SI Units  199
4. Use the fraction portion of the answer as the new value of x.
5. Repeat the procedure until the required number of random numbers is
generated.
si units ■
*
“SI units” stands for le Système international d’Unités, or International
System of Units. It is a system of reporting numerical values that promotes
the interchangeability of information between nations and between disci
plines. It consists of seven base units (Table 6–6) from which other units are
derived (Table 6–7). There are two supplemental units, the radian for the
plane angle and the steradian for the solid angle. The definitions of the base
units are listed in the next section. Tables 6–8, 6–9, 6–10, and 6–11 contain
further information on units of measurement.
Table 6–6 Base Units of SI
Physical Quantity Base Unit SI Symbol
Length Meter m
Mass Kilogram kg
Time Second s
Amount of substance Mole mol
Thermodynamic temperature Kelvin K
Electric current Ampere A
Luminous intensity Candela cd
Table 6–7 Representative Derived Units
Derived Unit Name (Symbol) Derivation From Base Units
Area Square meter m
2
Volume Cubic meter m
3
Force Newton (N) kg?m?s
22
Pressure Pascal (Pa) kg?m
21
?s
22
(N/m
2
)
Work, energy Joule (J) kg?m
2
?s
22
(N?m)
Mass density Kilogram/cubic meter kg/m
3
Frequency Hertz (Hz) s
21
*Portions of this section are reprinted with permission from Respir Care 33 1988:861–873.
84096_CH06_Chatburn.indd 199 6/18/10 12:14:31 PM
200  CHAPTER 6 Mathematical Procedures
Table 6–8 Prefixes and Symbols for Decimal Multiples and Submultiples
Factor Prefix Symbol
10
18
exa E
10
15
peta P
10
12
tera T
10
9
giga G
10
6
mega M
10
3
kilo k
10
2
hecto h
10
1
deka da
10
21
deci d
10
22
centi c
10
23
milli m
10
26
micro m
10
29
nano n
10
212
pico p
10
215
femto f
10
218
atto a
Factors in bold do not conform to the preferred incremental changes of 10
3
and 10
23
but are
still used outside medicine. Note that in use, they are written in plain rather than boldface
type.
Table 6–9 SI Style Specifications
Specifications Example Incorrect
Style
Correct
Style
Use lowercase for symbols or
abbreviations.
Kilogram Kg kg
Exceptions: Kelvin k K
Ampere a A
Liter l L
Symbols are not followed by a
period except at the end of a
sentence.
Meter m. m
Do not pluralize symbols. Kilograms kgs kg
(continued)
84096_CH06_Chatburn.indd 200 6/18/10 12:14:31 PM
SI Units  201
Table 6–9 SI Style Specifications (continued)
Specifications Example Incorrect
Style
Correct
Style
Names and symbols are not to be
combined.
Force kilogram?
meter?s
22
kg?m?s
22
When numbers are printed, sym
bols are preferred.
100 meters 100 m
2 moles 2 mol
Use a space between the number
and symbol.
50mL 50 mL
The product of units is indicated
by a dot above the line.
kg 3 m/s
2
kg?m?s
22
Use only one virgule (/) per
expression.
mmol/L/s mmol/(L?s)
Place a zero before the decimal. .01 0.01
Decimal numbers are preferable to
fractions and percents.
3/4 0.75
75% 0.75
Spaces are used to separate long
numbers (optional for fourdigit
number).
1,500,000 1 500 000
1,000 1000 or 1 000
Table 6–10 Currently Accepted NonSI Units
Quantity Name Symbol Value in SI Units
Time Minute min 1 min 5 60 s
Hour h 1 h 5 60 min 5 3 600 s
Day d 1 d 5 24 h 5 86 400 s
Plane angle Degree 8 18 5 (p/180) rad
Minute 9 19 5 (1/60)8 5 (p/10 800) rad
Second 0 10 5 (1/60)9 5 (p/648 000) rad
Volume Liter L 1 L 5 1 dm
3
5 10
23
m
3
Mass Ton (metric) t 1 t 5 10
3
kg
Area Hectare ha 1 ha 5 1 hm
2
5 10
4
m
2
84096_CH06_Chatburn.indd 201 6/18/10 12:14:31 PM
202  CHAPTER 6 Mathematical Procedures
Table 6–11 Conversion Factors for Units Commonly Used in Medicine
Physical Quantity Conventional Unit SI Unit Conversion
Factor
*
Length Inch (in.) meter (m) 0.0254
Foot (ft) m 0.3048
Area in.
2
m
2
6.452 3 10
24
ft
2
m
2
0.09290
Volume dL (5 100 mL) L 0.01
ft
3
m
3
0.02832
ft
3
L 28.32
Fluid ounce S mL 29.57
Amount of
substance
mg/dL mmol/L 10/mol wt
mEq/L mmol/L valence
mL of gas at STPD mmol 0.04462
Force Pound (lb) newton (N) 4.448
Dyne N 0.00001
Kilogramforce N 9.807
Pound S kilogram
force
0.4536
Ounce S gramforce 28.35
Pressure cm H
2
O kilopascal (kPa) 0.09806
mm Hg (torr) kPa 0.1333
Pounds/in.
2
(psi) kPa 6.895
psi S cm H
2
O 70.31
cm H
2
O S torr 0.736
Standard atmosphere kPa 101.3
Millibar (mbar) kPa 0.1000
Work, energy Calorie (c) joule (J) 4.185
Kilocalorie (C) J 4185
British thermal unit
(BTU)
1055
Surface tension dyn/cm N/m 0.001
Compliance L/cm H
2
O L/kPa 10.20
(continued)
84096_CH06_Chatburn.indd 202 6/18/10 12:14:31 PM
Definitions of Basic Units  203
Table 6–11 Conversion Factors for Units Commonly Used in Medicine (continued)
Physical Quantity Conventional Unit SI Unit Conversion
Factor
*
Resistance
airway cm H
2
O?s?L
21
kPa?s?L
21
0.09806
vascular dyn?s?cm
25
kPa?s?L
21
0.1000
mm Hg?min?L
21
kPa?s?L
21
7.998
Gas diffusion mL?s
21
?cm H
2
O
21
mmol?s
21
?
kPa
21
0.4550
Gas transport mL/min mmol/min 0.04462
Temperature 8C K K 5 8C + 273.15
8F S 8C 8C 5 (°F 2 32)/1.8
8C S 8F 8F 5 (1.8?8C)
+ 32
*
To convert from conventional to SI unit, multiply conventional unit by conversion factor. To convert in the
opposite direction, divide by conversion factor. Examples: 10 torr 5 10 3 0.133 3 kPa 5 1.333 kPa, 1 L 5
1 L/0.10 5 10 dL.
deFinitions oF basic units ■
Ampere. “That constant current which, if maintained in two straight parallel
conductors of infinite length, would produce between these conductors a
force equal to 2 3 10
27
newton per meter of length.” (CPGM, 1948)
Candela. “The luminous intensity, in the perpendicular direction, of a sub
stance of 1/600 000 square meter of black body at the temperature of
freezing platinum under a pressure of 101 325 newton per square meter.”
(13th CPGM, 1967)
Kelvin. “The fraction of 1/273.16 of the temperature of the triple point of
water.” (13th CPGM, 1967) The triple point of water is the temperature
at which ice, water, and vapor coexist in equilibrium at a temperature of
+0.00758C and a pressure of 610.6 newton/m
2
.
Kilogram. “Equal to the mass of the international prototype of the kilogram
(held at Sevres).” (3rd CPGM, 1901)
Meter. “Equal to 1 650 763.73 wavelengths in vacuum of the radiation cor
responding to the transition between the levels 2p
10
and 5d
5
of the kryp
ton86 atom.” (11th CPGM
*
, 1960)
*
CPGM stands for General Conference of Weights and Measures.
84096_CH06_Chatburn.indd 203 6/18/10 12:14:31 PM
204  CHAPTER 6 Mathematical Procedures
Mole. “The amount of substance of a system which contains as many ele
mentary entities as there are atoms in 0.012 kilogram of carbon 12.” (14th
CGPM, 1971) When the mole is used, the elementary entities must be
specified and may be atoms, molecules, ions, electrons, other particles, or
specified groups of such particles.
Radian. The unit of measure for plane angles, defined as the angle subtended
at the center of a circle by an arc whose length is equal to the radius of
the circle. In general, angle (radians) 5 arc length/radius. Since the cir
cumference of a circle is equal to 2 ?p radius of circle, a revolution of
3608 equals 2 ?p radians. Radian measure is much easier to work with
than degrees, minutes, and seconds, and is also more practical for use
with computers.
Second. “The duration of 9 192 631 770 periods of the radiation correspond
ing to the transition between the two hyperfine levels of the ground state
of the cesium133 atom.” (13th CPGM, 1967)
Steradian. The analogous unit of (radian) measure for solid angles. There
are 4 ?p steradians in a sphere.
Physical Quantities in resPiratory ■
Physiology
The dimensions of the physical quantities described here are in mass/length/
time units. These units provide a way of checking the validity of equations
and other expressions used in the study of respiratory physiology. That is, the
same mass/length/time units must be on both sides of an equation, and only
identical mass/length/time units can be added or subtracted.
Volume (dimensions: length
3
). Although the cubic meter (m
3
) is the SI base
unit for volume, the cubic decimeter (dm
3
), given the name liter, has been
accepted as the reference volume for stating concentrations. The cubic cen
timeter (cm
3
) or milliliter (mL) may still be used as a volume unit other than
as the denominator of a concentration unit.
According to J. F. Nunn, Applied Respiratory Physiology, 2nd ed. (London:
Butterworths, 1978):
It is not good practice to report gas volumes under the conditions
prevailing during their measurement. In the case of oxygen uptake,
carbon dioxide output and the exchange of “inert” gases, we need to
know the actual quantity (i.e., number of molecules) of gas exchanged
84096_CH06_Chatburn.indd 204 6/18/10 12:14:31 PM
Physical Quantities in Respiratory Physiology  205
and this is most conveniently expressed by stating the gas volume as it
would be under standard conditions . . . (pp. 445–452)
Standard conditions are 273.15K (08C), 101.3 kPa (760 torr) pressure, and
dry (STPD). When volumes relate to anatomic measurements such as tidal
volume or vital capacity, they should be expressed as they would be at body
temperature and pressure, saturated (BTPS). Conversions between ambient,
body, and standard conditions are made using tables or equations.
Amount of substance (dimensionless). The concentration of chemical sub
stances is reported primarily in moles per liter (mol/L) or some multiple
thereof (e.g., mmol/L). When the molecular weight of a substance is not
known, the unit may be grams per liter (g/L). (Note that 1 mg/mL 5 1 g/L
5 1 kg/m
3
.) Because water is not thought of as a chemically active substance
for the purposes of humidification, it would appear that absolute humidity
should still be reported in terms of weight instead of moles (i.e., mg/L). For
ideal gases such as oxygen and nitrogen, 1 mole occupies 22.4 L at STPD.
Therefore, the sum of the concentrations of ideal gases in a mixture would be
44.6 mmol/L.
Equivalent weights (e.g., milliequivalents) are related to molar concentrations
by their ionic valence. That is, equivalent weight equals mole/valence.
Example
Thus, for example, one equivalent weight of serum calcium is 1 mole
(1 gram molecular weight, 40.08 g) divided by 2 (the valence) or 20.02
equivalents. In applying this to clinical practice, we start with a normal
value for calcium, which is conventionally reported as 8.8 mg/dL. First
we convert to mg/L: (8.8 mg/dL) 3 10 dL/L) 5 88 mg/L. Next, we con
vert to mmol/L: (88 mg/L) 3 (1 mmol/40.08 mg) 5 2.20 mmol/L. Serum
ionized calcium (Ca
2+
) is reported as milliequivalents per liter (mEq/L).
Suppose a value for ionized calcium is reported as 2.00 mEq/L. To convert
to mmol/L, (2.00 mEq/L) 3 (1 mmol/2 mEq) 5 1.00 mmol/L. Converting
the other way, (1.00 mmol/L) 3 (2 mEq/1 mmol) 5 2.00 mEq/L. For uni
valent ions such as sodium, potassium, chloride, and bicarbonate, mEq/L
and mmol/L are numerically equal.
Volume flow rate (dimensions: length
3
?time
21
). Volume flow rate is a
special case of mass flow rate. We are generally interested in flow into and
out of the airways and how this changes lung volume. We therefore speak of
84096_CH06_Chatburn.indd 205 6/18/10 12:14:31 PM
206  CHAPTER 6 Mathematical Procedures
volume as if it flows—flows are expressed in liters per minute, for example.
This shorthand notation overlooks an important physical fact: Gases flow;
volumes do not. When we speak of a volume flow of so many liters per min
ute, what we are really saying is that the mass of gas that has exited from
the lung over that time would occupy a volume of so many liters at some
specific temperature and pressure. Thus, flow measurements require accurate
temperature and pressure measurements to be accurate. Gas exchange rates
should be corrected to STPD, while ventilatory gas flow rates should be cor
rected to BTPS. As a rule of thumb, gas volumes at STPD are about 10%
less than at ATPS, while volumes at BTPS are about 10% more. Units of
liters per minute (L/min), liters per second (L/s), and milliliters per minute
(mL/min) are acceptable at present.
Force (dimensions: mass?length?time
22
). Force is defined as mass times
acceleration. The SI unit of force, the newton (N), is defined as the force that
will give a mass of 1 kilogram an acceleration of 1 meter per second squared
(kg?m?s
22
).
One type of force that is in common usage is that due to gravity acting on a
standard mass. This force is interpreted as weight (i.e., weight equals mass
times acceleration due to gravity). In the British system, for example, a force
of 1 pound is produced when a mass of 1 slug is accelerated at the rate of 1
foot per second per second. In the metric system, weights are often expressed
in grams or kilograms. Although these units are not units of force (i.e., the
weight of a 1kg mass is 1 N), they are used as such and sometimes referred
to as gramforce or kilogramforce. What is implied is that a mass of 1 gram
(or kilogram) experiences a force due to standard conditions of gravity (9.8
m/s
2
or 32 ft/s
2
) , or “one unit” of acceleration. Thus, 1 gramforce equals
1 gram mass times 1 unit of acceleration. This is the basis for converting
pounds to kilograms and vice versa. Therefore, to say that 10 kilograms
“equals” 22 pounds means that the 10kilogram mass experiences a force
of 22 pounds under standard conditions of gravity (i.e., 0.6852 slug?32 ft?
s
22
). At the present time, the kilogramforce is being retained as the standard
unit to express weight for medical purposes.
The problem with this convention, aside from the fact that it is confusing, is
that the force of gravity varies from point to point on Earth. Therefore, the
weight of 1kilogram mass, determined, for instance, with a spring scale, will
vary depending on where on Earth it is measured. In space, where gravity is
nil, the weight would be zero. Hence, the kilogramforce is a poor unit for
standardization.
84096_CH06_Chatburn.indd 206 6/18/10 12:14:31 PM
Physical Quantities in Respiratory Physiology  207
Pressure (dimensions: mass?length
21
?time
22
). In respiratory physiology,
force is generally expressed as pressure, defined as force per unit area. The
SI unit of force, the pascal (Pa), is defined as 1 newton per square meter
(1 N/m
2
). However, the pascal is inconveniently small (equivalent to about
l/10,000th of an atmosphere), so the kilopascal (kPa) has been proposed for
general use in medicine. Thus, a kilopascal is about 1% of an atmosphere.
A standard atmosphere is 101.3 kPa, and the partial pressure of oxygen in
dry air is approximately 21 kPa. One kPa is approximately 10 centimeters
of water (cm H
2
O). The millimeter of mercury (mm Hg) and the centimeter
of water are two gravitybased units used in medicine that will eventually be
replaced for reporting gas pressures. Currently, however, medical journals
are still using these units. It appears that mm Hg may be retained indefinitely
for reporting blood pressure.
Work and energy (dimensions: mass?length
2
?time
22
). According to the
work–energy theorem, the work done on a body by an applied force is equal
to the change in kinetic energy of the body. Work is done when a force
moves a body a given distance, or when gas is moved in response to a pres
sure gradient. In the SI, the unit of work is the joule (J), defined as the work
done when a force of 1 newton moves a body a distance of 1 meter (i.e.,
1 N?m), or when a liter of gas moves in response to a pressure gradient of
1 kilopascal (i.e., 1 L?kPa). The erg and calorie will no longer be used.
Because pressure times volume yields dimensions of energy, pressure can be
interpreted as energy density (energy per unit volume). Thus, if the pressure
of a system increases, it reflects a change in energy of the system, meaning
that some outside agency has done work on it. When the pressure is released,
useful work may be recovered. This is the principle used by air rifles and
ventilators powered by compressed gas.
Power (dimensions: mass?length
2
?time
23
). Power is defined as the rate of
change of work. The SI unit is the watt (W), defined as 1 joule per second.
This unit provides a convenient link with electrical units because 1 watt
equals 1 ampere times 1 volt.
Surface tension (dimensions: mass?time
22
). Surface tension is defined as a
force per unit length existing at a liquid surface. In SI units, surface tension
would be expressed as the newton per meter, which is equal to 1 Pa?m or
1 kg?s
22
. The unit for surface tension is likely to be called the pascalmeter.
One millipascalmeter is equal to the conventional centimetergramsecond
unit (CGS) the dyne/centimeter (dyn/cm).
84096_CH06_Chatburn.indd 207 6/18/10 12:14:31 PM
208  CHAPTER 6 Mathematical Procedures
Compliance (dimensions: mass?length
24
?time
22
). Compliance is defined
as the change in the volume of a system divided by the corresponding change
in the pressure difference across the walls of the system (i.e., the slope of the
pressurevolume curve). In SI units, compliance would be expressed as liter
per kilopascal (L/kPa). The reciprocal, elastance, has units of kilopascal per
liter.
Resistance (dimensions: mass?length
24
?time
21
). Resistance to laminar
flow is defined as the change in the pressure difference causing flow divided
by the associated change in flow rate (i.e., the slope of the flowpressure
curve). The appropriate SI units are kPa?L
21
?s. The reciprocal, conduc
tance, has units of kPa
21
?L?s
21
.
Solubility (dimensions: time?length
21
). The solubility of a gas in liquid has
been expressed in many different units. This is simplified in SI units as mmol
?L
1
?kPa
21
, which has been given the name capacitance coefficient. This
coefficient varies only with temperature when a solution obeys Henry’s law.
For solutions with a nonlinear dissociation curve (e.g., oxygen in blood), the
capacitance coefficient would be defined between two points (arterial and
venous) as difference in concentration (mmol?L
1
) divided by difference in
partial pressure (kPa).
Temperature. Although the SI unit for temperature is the kelvin (K), some
medical journals still use the Celsius scale. Temperatures expressed in
degrees kelvin and Celsius both have the samesized increments, but the kel
vin scale offers the advantage of being a ratio rather than an interval scale.
Thus, it has an absolute zero that makes possible statements like, “The tem
perature in group A was 5% higher than group B.”
84096_CH06_Chatburn.indd 208 6/18/10 12:14:31 PM
APPENDIX
APPENDIX
Reference Data
84096_APPX_Chatburn.indd 209 6/18/10 8:30:50 AM
210  Appendix Reference Data
CliniCal abbreviations ■
aa of each
a.c. before meals
Ad. lib. as desired
AG anion gap
Ant. anterior
ante before
Aq. water
bid twice daily
bpm beats per minute
c with
cc cubic centimeters
CI cardiac index
comp compound
CO cardiac output
DC discontinue
dL deciliter (= 100 mL)
dr dram
g gram
gtt drop
kg kilogram
mg microgram
mEq milliequivalent
mg milligram
mL milliliter
nmol nanomole
p after
PEEP positive endexpiratory
pressure
PIP peak inspiratory pressure
PO by mouth
PR rectal
prn as needed
pt pint
q every
qd every day
qh every hour
q2h every two hours
qhs at bedtime
qid four times a day
qt quart
s without
SI stroke index
sol solution
stat immediately
STP standard temperature and
pressure
tid three times daily
vol% volume percent
84096_APPX_Chatburn.indd 210 6/18/10 8:30:50 AM
Physiological Abbreviations  211
PhysiologiCal abbreviations ■
The terminology and abbreviations listed here are those suggested by the
American College of Chest Physicians and the American Thoracic Society
Joint Committee.
Xa or Xa A small capital letter or lowercase letter on the same line
following a primary symbol is a qualifier to further define
the primary symbol. When small capital letters are not
available, large capital letters may be used as subscripts,
e.g., Xa = X
A
.
ATPD Ambient temperature and pressure, dry
ATPS Ambient temperature and pressure, saturated with water
vapor at these conditions
b Barometric (qualifying symbol)
BTPS Body conditions: body temperature, ambient pressure, and
saturated with water vapor at these conditions
C A general symbol for compliance; volume change per unit
of applied pressure; concentration
c Capillary
c9 Pulmonary end capillary
C/Vl Specific compliance
CD Cumulative inhalation dose. The total dose of an agent
inhaled during bronchial challenge testing; it is the sum of
the products of concentration multiplied by the number of
breaths at that concentration.
Cdyn Dynamic compliance: compliance measured at point of zero
gas flow at the mouth during active breathing. The respira
tory frequency should be designated; e.g., Cdyn 40.
C
st
Static compliance; compliance determined from measure
ments made during conditions of prolonged interruption of
airflow
D/Va Diffusion per unit of alveolar volume
Dk Diffusion coefficient or permeability constant as described
by Krogh; it equals D ? (Pb 2 PH
2
O)/Va
Dm Diffusing capacity of the alveolar capillary membrane
(STPD)
84096_APPX_Chatburn.indd 211 6/18/10 8:30:50 AM
212  Appendix Reference Data
Dx (e.g., DLco) Diffusing capacity of the lung expressed as volume (STPD)
of gas (x) uptake per unit alveolar capillary pressure dif
ference for the gas used. Unless otherwise stated, carbon
monoxide is assumed to be the test gas, i.e., D is Dco. A
modifier can be used to designate the technique, e.g., Dsb
is singlebreath carbon monoxide diffusing capacity and
Dss is steadystate carbon monoxide diffusing capacity.
(Author’s note: This recommendation has not been widely
accepted. Dl
co
, Dl
co
sb, and Dl
co
ss are still the most com
monly used abbreviations.)
e Expired (qualifying symbol)
ERV Expiratory reserve volume; the maximum volume of air
exhaled from the endexpiratory level
est Estimated
f Ventilator frequency
f
b
Breathing frequency
F Fractional concentration of a gas
FEFmax The maximum forced expiratory flow achieved during the
FVC
FEF
25%–75%
Mean forced expiratory flow during the middle half of the
FVC (formerly called the maximum midexpiratory flow
rate)
FEF
75%
Instantaneous forced expiratory flow after 75% of the FVC
has been exhaled
FEF
200–1200
Mean forced expiratory flow between 200 mL and 1200 mL
of the FVC (formerly called the maximum expiratory flow
rate)
FEF
x
Forced expiratory flow, related to some portion of the FVC
curve. Modifiers refer to the amount of the FVC already
exhaled when the measurement is made.
FET
x
The forced expiratory time for a specified portion of the
FVC; e.g., FET
95%
is the time required to deliver the first
95% of the FVC and FET
25%–75%
is the time required to
deliver the FEF
25%–75%
FEV Forced expiratory volume
FEV/FVC% Forced expiratory volume (timed) to forced vital capacity
ratio, expressed as a percentage
84096_APPX_Chatburn.indd 212 6/18/10 8:30:50 AM
Physiological Abbreviations  213
FIF
x
Forced inspiratory flow. As in the case of the FEF, the
appropriate modifiers must be used to designate the volume
at which flow is being measured. Unless otherwise speci
fied, the volume qualifiers indicate the volume inspired
from RV at the point of the measurement.
FRC Functional residual capacity; the sum of RV and ERV (the
volume of air remaining in the lungs at the endexpiratory
position). The method of measurement should be indicated,
as with RV.
FVC Forced vital capacity
Gaw Airway conductance, the reciprocal of Raw
Gaw/Vl Specific conductance, expressed per liter of lung volume at
which G is measured (also referred to as sGaw)
i Inspired (qualifying symbol)
IRV Inspiratory reserve volume; the maximum volume of air
inhaled from the endinspiratory level
IC Inspiratory capacity; the sum of IRV and Vt
l Lung (qualifying symbol)
max Maximum
MIP Maximum inspiratory pressure
MEP Maximum expiratory pressure
MVV
x
Maximum voluntary ventilation. The volume of air expired
in a specified period during repetitive maximum respiratory
effort. The respiratory frequency is indicated by a numerical
qualifier; e.g., MVV
60
is MW performed at 60 breaths per
minute. If no qualifier is given, an unrestricted frequency is
assumed.
OI Oxygenation index
p Physiologic
P Pressure, blood or gas
PA Pulmonary artery
Paw Airway pressure
PD Provocative dose; the dose of an agent used in bronchial
challenge testing that results in a defined change in a spe
cific physiologic parameter. The parameter tested and the
percent change in this parameter is expressed in cumulative
84096_APPX_Chatburn.indd 213 6/18/10 8:30:50 AM
214  Appendix Reference Data
dose units over the time following exposure that the posi
tive response occurred. For example, PD
35
sGaw = x units/y
minutes, where x is the cumulative inhalation dose and y the
time at which a 35% fall in sGaw was noted.
PEF Peak expiratory flow: the highest forced expiratory flow
measured with a peak flowmeter
pred Predicted
P
st
Static transpulmonary pressure at a specified lung volume;
e.g., P
st
TLC is static recoil pressure measured at TLC (max
imal recoil pressure)
Q Volume of blood
Q
c
Capillary blood volume (usually expressed as V
c
in the lit
erature, a symbol inconsistent with those recommended for
blood volumes). When determined from the following equa
tion, Q
c
represents the effective pulmonary capillary blood
volume, that is, capillary blood volume in intimate associa
tion with alveolar gas: I/D = I/D
m
+ I/(U ? Q
c
).
Raw Airway resistance
rb Rebreathing
RQ Respiratory quotient
R
us
Resistance of the airways on the alveolar side (upstream) of
the point in the airways where intraluminal pressure equals
intrapleural pressure, measured under conditions of maxi
mum expiratory flow
RV Residual volume; that volume of air remaining in the lungs
after maximum exhalation. The method of measurement
should be indicated in the test or, when necessary, by
appropriate qualifying symbols.
SBN Singlebreath nitrogen test; a test in which plots of expired
nitrogen concentration versus expired volume after inspira
tion of 100% oxygen are recorded. The closing volume and
slope of phase III are two parameters measured by this test.
STPD Standard conditions: temperature 08C, pressure 760 mm Hg,
and dry (0 water vapor)
t Time (qualifying symbol)
t Tidal
TGV Thoracic gas volume; the volume of gas within the thoracic
cage as measured by body plethysmography
84096_APPX_Chatburn.indd 214 6/18/10 8:30:50 AM
Physiological Abbreviations  215
TLC Total lung capacity; the sum of all volume compartments
or the volume of air in the lungs after maximal inspiration.
The method of measurement should be indicated, as with
RV.
V Gas volume. The particular gas as well as its pressure,
water vapor conditions, and other special conditions must
be specified in text or indicated by appropriate qualifying
symbols.
v Venous
v Mixed venous
V
#
A Alveolar ventilation per minute (BTPS)
V
#
CO
2
Carbon dioxide production per minute (STPD)
V
#
D Ventilation per minute of the physiologic dead space (wast
ed ventilation), BTPS, defined by the following equation:
V
#
D 5 V
#
E1PaCO
2
2 PECO
2
>1PaCO
2
2 PICO
2
2
Vd The physiologic deadspace volume defined as V
#
D>f
Vdan Volume of the anatomic dead space (BTPS)
V
#
E Expired volume per minute (BTPS)
V
#
I Inspired volume per minute (BTPS)
VisoV
#
Volume of isoflow; the volume when the expiratory flow
rates become identical when flowvolume loops performed
after breathing room air and helium–oxygen mixtures are
compared
V
#
O
2
Oxygen consumption per minute (STPD)
V
#
max X Forced expiratory flow, related to the total lung capacity or
the actual volume of the lung at which the measurement is
made. Modifiers (X) refer to the amount of the lung volume
remaining when the measurement is made. For example,
V
#
max 75% is instantaneous forced expiratory flow when
the lung is at 75% of its TLC. V
#
max 3.0 is instantaneous
forced expiratory flow when the lung volume is 3.0 L.
[Author’s note: It is still common to find reports in which
modifiers refer to the amount of VC remaining.]
Vt Tidal volume; TV is also commonly used
84096_APPX_Chatburn.indd 215 6/18/10 8:30:51 AM
216  Appendix Reference Data
bloodgas MeasureMents ■
Abbreviations for these values are readily composed by combining the gen
eral symbols recommended earlier. The following are examples:
Paco
2
Arterial carbon dioxide tension
Po
2
Partial pressure of oxygen
Fio
2
Fraction of inspired air
Pa Alveolar pressure
Va Alveolar volume
C(a–v)o
2
Arteriovenous oxygen content difference
Cc9o
2
Oxygen content of pulmonary end capillary blood
Feco Fractional concentration of carbon dioxide in expired gas
P(a–a)o
2
Alveolar–arterial oxygen pressure difference; the previously used
symbol, A–aDO
2
, is not recommended.
Sao
2
Arterial oxygen saturation of hemoglobin
Q
#
S Physiologic shunt flow (total venous admixture) as a fraction of
total blood flow (Q
#
T) defined by the following equation when
gas and blood data are collected during ambient air breathing:
Q
#
S 5
Cc¿O
2
2 CaO
2
Cc¿O
2
2 CvO
2
? QT
Peto
2
Po
2
of endtidal expired gas
FCo
2
Fractional concentration of oxygen
R A general symbol for resistance, pressure per unit flow
Re Respiratory exchange ratio
REE Resting energy expenditure
S Saturation in the blood phase
sat Saturated
sGaw Specific airway conductance
So
2
Oxygen saturation
T Temperature
TCT Total cycle time
Te Expiratory time
Ti Inspiratory time
VC Vital capacity
84096_APPX_Chatburn.indd 216 6/18/10 8:30:51 AM
Basic Pharmacological Formulas and Definitions  217
basiC PharMaCologiCal ForMulas and ■
deFinitions
Solutions: Definitions and Terms
Solution: a homogeneous mixture (usually liquid) of the molecules, atoms,
or ions of two or more different substances.
Solute: the dissolved substance (which may be a gas, liquid, or solid) in a
solution.
Solvent: the dissolving medium in a solution.
Isotonic solutions: solutions having equal osmotic pressure.
Buffer solutions: aqueous solution able to resist changes of pH with addition
of acid or base.
Gram molecular weight: the atomic weight of a compound expressed in
grams. The gram molecular weight (formula weight) is the weight of a
mole of the substance.
Equivalent weight: the weight of a substance that either receives or donates
1 mole of electrons. One gram equivalent weight of any electrolyte has
the same chemical combining power as 1 gram of hydrogen. The equiva
lent weight of a substance is calculated by the equation:
Equivalent weight 5
gram molecular weight
valence
Milliequivalent (mEq): onethousandth of an equivalent weight.
Normal solution: 1 gram equivalent weight of solute per liter of solution.
This should not be confused with the term “normal saline,” which is used
to designate a solution that is isotonic with human body fluid. Normal
saline is a 0.9% solution of sodium chloride or 9 g per 1,000 mL.
Molar solution: 1 mole of solute per liter of solution.
Molal solution: 1 mole of solute per 1,000 grams of solvent.
Osmole solution: molarity 3 number of particles per molecule.
Osmolar solution: 1 osmole per liter of solution. The osmolality of extracel
lular fluid can be calculated according to the formula
serum osmolality 1mOsm>kg2 5 2 3 Na 1mEq>L2 1
glucose 1mg>dL2
18
1
BUN 1mg>dL2
2.8
1
ETOH 1mg>dL2
4.6
1
isopropanolol 1mg>dL2
6
1
methanol 1mg>dL2
3.2
1
ethylene glycol 1mg>dL2
6.2
84096_APPX_Chatburn.indd 217 6/18/10 8:30:51 AM
218  Appendix Reference Data
Drug Dosage Calculation
Calculating Dosages from Stock Solutions, Tablets, or Capsules
1. Convert all measurements to the same unit.
2. Set up the following proportion:
Original drug strength
Amount supplied
5
Prescribed dosage
Unknown amount to be supplied
.
3. Calculate the dosage.
Example
Your patient is going to surgery. She weighs 60 kg, and the physician ordered 0.02
mg/kg of atropine preoperatively. You only have tablets of 0.4 mg/tablet strength.
How many tablets do you give the patient?
Original drug strength = 0.4 mg
Amount supplied = 1 tablet
Prescribed dosage = 0.02 mg/kg 3 60 kg = 1.2 mg
Amount to be given = x
Using the above formula, we get
0.4 mg
1 tablet
5
1.2 mg
x tablets
0.4x 5 1.2
x 5 1.2>0.4 5 3 tablets.
Calculating Dosages from PercentStrength Solutions
Types of Percentage Preparations
Weight to weight: the number of grams of active ingredient in 100 g of a
mixture.
Weight to volume: the number of grams of active ingredient in 100 mL of
a mixture.
Volume to volume: the number of milliliters of active ingredient in 100
mL of a mixture.
84096_APPX_Chatburn.indd 218 6/18/10 8:30:52 AM
Basic Pharmacological Formulas and Definitions  219
1. When preparing percentage solutions, the following rule applies:
A 1.0% solution contains 1.0 g in 100 mL.
A 0.1% solution contains 0.1 g in 100 mL. This is based on the fact
that 1.0 mL of H
2
O at STP has a mass of 1.0 g (Table A1).
2. Calculate the weight strength.
Table A–1 Percentage Concentrations of Solutions
*
Percentages Ratio g/mL mg/mL
100 1:1 1 1000
10 1:10 0.1 100
5 1:20 0.05 50
1 1:100 0.01 10
0.5 1:200 0.005 5
0.1 1:1,000 0.001 1
*
Weight to volume.
Example
How much isuprel is delivered in an aerosol composed of 0.5 mL 1:200 isoproterenol
(Isuprel) in 3.0 mL of saline?
Answer
A 1:200 solution contains 5 mg of drug per mL. Thus, 0.5 ml of a 1:200 (weight to vol
ume) solution contains 0.5 mL 3 5 mg/mL = 2.5 mg of drug. Therefore, the aerosol
contains 2.5 mg of isoproterenol in a total of 3.5 mL of solution (0.5 mL isoprotere
nol + 3.0 mL saline, which is a 1:6 volume to volume ratio).
Unfortunately, the “ratio by simple parts” prescription still persists. For
instance, a physician may order aerosol therapy with a 1:8 solution of iso
etharine. This indicates one part medication to eight parts diluent. However,
this type of prescription does not specify the actual dosage of isoetha
rine (either volume or weight) or the units, although usually milliliters is
assumed.
84096_APPX_Chatburn.indd 219 6/18/10 8:30:52 AM
220  Appendix Reference Data
MisCellaneous reFerenCe data ■
Table A–2 Measurement Units
The Apothecary System The Avoirdupois System
Weight Weight
20 grains = 1 scruple 437.5 grains = 1 ounce
3 scruples = 1 dram 16 ounces = 1 pound
8 drams = 1 ounce 7,000 grains = 1 pound
12 ounces = 1 pound
Volume
60 minims = 1 fluid dram
8 fluid drams = 1 fluid ounce
16 fluid ounces = 1 pint
2 pints = 1 quart
4 quarts = 1 gallon
Table A–3 Approximate Conversion Equivalents
Liquid
Metric Apothecary Household
1 liter (1000 mL) 1 quart (2 pints) 2 tumblerfuls
500 milliliters (mL) 1 pint (16 fluid ounces) 3 teacupfuls
360 mL 12 fluid ounces (1 pound) 2 teacupfuls
30 mL 1 ounce (8 drams) 2 tablespoonfuls
4 mL 1 dram (60 minims) 1 small teaspoonful
1 mL 16 minims 1/4 teaspoonful
0.06 mL 1 minim 1 drop
Weight
Metric Apothecary Avoirdupois
1 kilogram (1000 grams) — 2.2 pounds
500 grams 7680 grains —
454 grams 5760 grains 1 pound (16 ounces)
29 grams 480 grains 1 ounce (437 grains)
4 grams 60 grains —
84096_APPX_Chatburn.indd 220 6/18/10 8:30:52 AM
Miscellaneous Reference Data  221
Table A–3 Approximate Conversion Equivalents (continued)
Weight
Metric Apothecary Avoirdupois
1 gram (1000 mg) 15 grains —
60 milligrams (mg) 1 grain 1 grain
1 mg (1000 micrograms) 1/60 grains —
Table A–4 Deposition of Aerosol Particles (Mouth Breathing)
Particle Size
(mm)
Maximum
Retention
(%) Site of Retention
.10 100 Pharynx, larynx, trachea
5 90–95 Larynx, bronchi, bronchioles
3 8.5 Bronchioles, acini
1 60 Acini
0.6 35 Alveoli (.60% may be exhaled)
,0.1 (0) Evaporate or coalesce
Table A–5 Physical Factors in Aerosol Deposition
Factor
Size/Type
Particle Site of Deposition Remarks
Inertial impaction High density .
10 mm
Nose, mouth, phar
ynx, larynx, airway
bifurcations
Increased with
high flow rate
Sedimentation
(gravity)
High density 1–6
mm
Bronchioles, acini Increased with
deep, slow breath
ing
Diffusion ,1 mm Entire pulmonary
tree, acini, alveoli
Increased with
breathholding
84096_APPX_Chatburn.indd 221 6/18/10 8:30:52 AM
222  Appendix Reference Data
Table A–6 Conversion Table for Temperature
*
8C 8F 8C 8F 8C 8F 8C 8F
15 59.0 26 78.8 37 98.6 48 118.4
16 60.8 27 80.6 38 100.4 49 120.2
17 62.6 28 82.4 39 102.2 50 122.0
18 64.4 29 84.2 40 104.0 51 123.8
19 66.2 30 86.0 41 105.8 52 125.6
20 68.0 31 87.8 42 107.6 53 127.4
21 69.8 32 89.6 43 109.4 54 129.2
22 71.6 33 91.4 44 111.2 55 131.0
23 73.4 34 93.2 45 113.0 56 132.8
24 75.2 35 95.0 46 114.8 57 134.6
25 77.0 36 96.8 47 116.6 58 136.4
*
To convert Celsius to Fahrenheit: To convert Fahrenheit to Celsius:
1. Multiply by 1.8 1. Subtract 32.
2. Add 32. 2. Divide by 1.8
Celsius Fahrenheit
0 Water freezes 32
22 Room temp. 72
37 Body temp. 98.6
100 Water boils 212
121 Autoclave temp. 250
84096_APPX_Chatburn.indd 222 6/18/10 8:30:52 AM
Miscellaneous Reference Data  223
Table A–7 Conversion Table for Volume
Volume cc In.
3
fl oz Quarts Liters
1 cc 1.00 0.061 0.0338 0.001057 0.00100
1 in.
3
16.39 1.00 0.554 0.0173 0.01639
1 fl oz 29.6 1.804 1.00 0.03125 0.0296
1 quart 946 57.75 32.0 1.00 0.946
1 liter 1000 61.0 33.8 1.056 1.00
Table A–8 Conversion Table for Weight
Weight gr g lb kg
1 grain (gr) 1.00 0.0648 0.0001429 0.0000648
1 gram (g) 15.43 1.00 0.002205 0.001000
1 pound (lb) 7000 454 1.00 0.454
1 kilogram (kg) 15432 1000 2.205 1.00
Table A–9 Conversion Table for Length
Length cm in. ft yd m
1 centimeter 1.00 0.394 00328 0.01094 0.0100
1 inch 2.54 1.00 0.0833 0.0278 0.0254
1 foot 30.48 12.0 1.00 0.333 0.305
1 yard 91.4 36.0 3.00 1.00 0.914
1 meter 100.0 39.4 3.28 1.094 1.00
1 kilometer 100,000 39,400 3280 1094 1000
1 mile 160,903 63,360 5280 1760 1609
84096_APPX_Chatburn.indd 223 6/18/10 8:30:52 AM
224  Appendix Reference Data
T
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84096_APPX_Chatburn.indd 224 6/18/10 8:30:52 AM
Miscellaneous Reference Data  225
Table A–11 Conversion Table for Tubes/Catheters
French
Approximate
Millimeters
(ID)*
Outside Diameter (OD)*
Inches Millimeters
6 1.0 0.079 2
8 1.5 0.105 2.7
10 2.0 0.131 3.3
12 2.5 0.158 4
14 3.0 0.184 4.7
16 3.5 0.210 5.3
18 4.0 0.236 6
20 4.5 0.263 6.7
22 5.0 0.288 7.3
24 5.5 0.315 8
26 6.0 0.341 8.7
28 6.5 0.367 9.3
30 7.0 0.398 10
32 7.5 0.420 10.7
34 8.0 0.446 11.3
*ID = inside diameter; OD = outside diameter.
84096_APPX_Chatburn.indd 225 6/18/10 8:30:52 AM
226  Appendix Reference Data
Table A–12 Conversion Table for Hypodermic Needle Tubing
Gauge Inches (OD) Inches (ID)
12 0.109 0.085
14 0.083 0.063
16 0.065 0.047
18 0.050 0.033
19 0.042 0.027
20 0.035 0.023
21 0.032 0.020
22 0.028 0.016
23 0.025 0.013
24 0.022 0.012
25 0.020 0.010
26 0.018 0.010
28 0.014 0.007
30 0.012 0.006
32 0.009 0.004
Table A–13 Average Body Surface Area (BSA) to Age, Weight, and Height
Age Height (in.) Weight (lb) BSA (m
2
)
Newborn 20 6.6 0.20
3 mo 21 11.0 0.25
1 yr 31 22.0 0.45
3 yr 38 32.0 0.62
6 yr 48 46.0 0.80
9 yr 53 66.0 1.05
15 yr 63 110.0 1.50
Adult 68 154.0 1.75
84096_APPX_Chatburn.indd 226 6/18/10 8:30:52 AM
Miscellaneous Reference Data  227
Table A–14 Body Surface Area (BSA) Prediction Equations
*
Infant (2.5–20 kg)
BSA (m
2
) = (3.6 wt + 9)/100
Child (20–40 kg)
BSA (m
2
) = (2.5 wt + 33)/100
General (Dubois)
BSA (m
2
) = wt
0.425
3 ht
0.725
3 0.00781
*
Weight in kg, height in cm.
Table A–15 Pediatric Body Surface Area (BSA) Chart
Infant Child
Weight (kg) BSA (m
2
) Weight (kg) BSA (m
2
)
3 0.20 20 0.83
4 0.23 22 0.88
5 0.27 24 0.93
6 0.31 26 0.98
7 0.34 28 1.03
6 0.31 30 1.08
9 0.41 32 1.13
10 0.45 34 1.18
11 0.49 36 1.23
12 0.52 38 1.28
13 0.56 40 1.33
14 0.59
15 0.63
16 0.67
17 0.70
18 0.74
19 0.77
20 0.81
84096_APPX_Chatburn.indd 227 6/18/10 8:30:52 AM
228  Appendix Reference Data
Table A–16 1983 Metropolitan Life Insurance Height and Weight Tables
*
Men
Height
ft in. (cm)
Small Frame
lb (kg)
Medium Frame
lb (kg)
Large Frame
lb (kg)
59 20 128–134 131–141 138–150
(157) (58–61) (60–64) (63–68)
59 40 132–138 135–145 142–156
(163) (60–63) (61–66) (65–71)
59 60 136–142 139–151 146–164
(168) (62–65) (63–69) (66–75)
59 80 140–148 145–157 152–172
(173) (64–67) (66–71) (69–78)
59 100 144–154 151–163 158–180
(178) (65–70) (69–74) (72–82)
69 00 149–160 157–170 164–188
(183) (68–73) (71–77) (75–85)
69 20 155–168 164–178 172–197
(188) (70–76) (75–81) (78–90)
69 40 162–172 171–187 181–207
(193) (74–78) (78–85) (82–94)
Women
Height
ft in. (cm)
Small Frame
lb (kg)
Medium Frame
lb (kg)
Large Frame
lb (kg)
49 100 102–111 109–121 118–131
(147) (46–50) (50–55) (54–60)
59 00 104–115 113–126 122–137
(152) (47–52) (51–57) (55–62)
59 20 108–121 118–132 128–143
(157) (49–055) (54–60) (58–65)
59 40 114–127 124–138 134–151
(163) (52–058) (056–63) (61–69)
84096_APPX_Chatburn.indd 228 6/18/10 8:30:53 AM
Miscellaneous Reference Data  229
Table A–16 1983 Metropolitan Life Insurance Height and Weight Tables
*
(continued)
Women
Height
ft in. (cm)
Small Frame lb
(kg)
Medium Frame
lb (kg)
Large Frame lb
(kg)
59 60 120–133 130–144 140–159
(168) (55–60) (59–65) (64–72)
59 80 126–139 136–150 146–167
(173) (57–63) (62–68) (66–76)
59 100 132–145 142–156 152–173
(178) (60–66) (65–71) (69–79)
69 00 138–151 148–162 158–179
(183) (63–69) (67–74) (72–81)
*
In shoes with 1in. heels and clothes weighing approximately 5 lb.
Table A–17 Comparative Nomenclature of Bronchopulmonary Anatomy
Jackson–Huber
Number (Color)
Key to Petit
Reviews Boyden Brock
Thoracic
Society of
Great Britain
Right Upper lobe
Apical 1 (Red) B
1
Apical Apical
Anterior 2 (Light blue) B
2
Pectoral Anterior
Posterior 3 (Green) B
3
Subapical Posterior
Right middle lobe
Lateral 4
R
(Purple) B
4
Lateral Lateral
Medial 5
R
(Orange) B
5
Medial Medial
Right lower lobe
Superior 6 (Lavender) B
6
Apical Apical
Medial basal 7 (Olive) B
7
Cardiac Medial basal
Anterior basal 8 (Yellow) B
8
Anterior
basal
Anterior basal
Lateral basal 9 (Red) B
9
Middle
basal
Lateral basal
(continued)
84096_APPX_Chatburn.indd 229 6/18/10 8:30:53 AM
230  Appendix Reference Data
Table A–17 Comparative Nomenclature of Bronchopulmonary Anatomy (continued)
Jackson–Huber
Number (Color)
Key to Petit
Reviews Boyden Brock
Thoracic
Society of
Great Britain
Posterior basal 10 (Turquoise) B
10
Posterior
basal
Posterior basal
Left upper lobe
Upper division 1–3 (Red) Upper division
Apical–posterior B
1&3
Apical and
subapical
Apicoposterior
or apical and
posterior
Anterior 2 (Light blue) B
2
Pectoral Anterior
Lower (lingular
division)
Superior lingular 4
L
(Purple) B
4
Superior
lingular
Superior lin
gular
Inferior lingular 5
L
(Orange) B
5
Inferior
lingular
Inferior lin
gular
Left lower lobe
Superior 6 (Lavender) B
6
Apical Apical
Anteromedial 8 (Yellow) B
7&8
Anterior Anterior basal
Lateral basal 9 (Red) B
9
Middle
basal
Lateral basal
Posterior basal 10 (Turquoise) B
10
Posterior
basal
Posterior basal
84096_APPX_Chatburn.indd 230 6/18/10 8:30:53 AM
Miscellaneous Reference Data  231
Table A–18 Incubator Temperatures According to Age
Age
(day)
Birth Weight
61500 g
Birth Weight
71500 g
Birth Weight
72500 g
and Gestation
736 wk
8C 8F 8C 8F 8C 8F
1st 34.3 93.8 33.4 92.1 33.0 91.4
2nd 33.7 92.7 32.7 90.9 32.4 90.4
3rd 33.5 92.3 32.4 90.4 31.9 89.4
4th 33.5 92.3 32.3 90.2 31.5 88.6
6th 33.5 92.3 32.1 89.8 30.9 87.6
8th 33.5 92.3 32.1 89.8 30.6 87.0
10th 33.5 92.3 32.1 89.8 30.2 86.4
12th 33.5 92.3 32.1 89.8 29.5 85.1
14th 33.4 92.1 32.1 89.8 — —
Table A–19 Airway and Alveolar Dimensions from Birth to Adult
Trachea Bronchus
Age
Length
(mm)
Diameter
(mm)
Length
(mm)
Diameter
(mm)
Number of
Alveoli
Birth 40 6 9 5.0 24 3 10
6
1 yr 43 7.8 11 6.3 129 3 10
6
5 yr 56 10 13.5 7.5 250 3 10
6
10 yr 63 11 14.7 8.6 280 3 10
6
16 yr 74 14 20 10.0 290 3 10
6
Adult 90–150 14–18 22 12.7 296 3 10
6
84096_APPX_Chatburn.indd 231 6/18/10 8:30:53 AM
232  Appendix Reference Data
Table A–20 Approximate Daily Requirements
of Calories and Water
Age
(yr)
Calories
(kg)
Water
(mL/kg)
Infancy 110 150
1–3 100 125
4–6 90 100
7–9 80 75
10–12 70 75
13–15 60 50
16–19 50 50
Adult 40 50
Table A–21 Capabilities of Disinfecting Agents Commonly Used in Respiratory Care
*
Disinfectant
Gram
Positive
Bacteria
Gram
Negative
Bacteria
Tubercle
Bacillus Spores Viruses Fungi
Soaps 0 0 0 0 0 0
Detergents
;
2 0 0 0 0
Quaternary ammonium
compounds
+
;
0 0
; ;
Acetic acid ? + ? ? ?
;
Alcohols + + + 0
; ;
Hot water (,1008C) + + +
; ;
?
Glutaraldehydes + + +
;
+ +
Hydrogen peroxide
based compounds
+ + +
;
+ +
Steam (.1008C) + + + + + +
Ethylene oxide + + + + + +
*
+ = good; ; = fair; 2 = poor; ? = unknown; 0 = little or none.
84096_APPX_Chatburn.indd 232 6/18/10 8:30:53 AM
Miscellaneous Reference Data  233
Table A–22 Variables and Calculated Parameters for Characterizing Nebulizer
Performance
Variable Symbol Primary Measured Variable or Equation
Output Flow OF Primary measured variable
Initial Charge IC Primary measured variable
Retained Charge RC Primary measured variable
Inhaled Aerosol IA Primary measured variable
Lung Deposition LD Primary measured variable
Output Aerosol OA OA = IC – RC
Output Rate OR
OR =
OA
NT
Inhaled Aerosol Rate IAR
IAR =
IA
NT
Wasted Aerosol WA WA = OA – IA = IC – RC – IA
Exhaled Aerosol EA EA = IA – LD
Nebulizer Efficiency NE
NE =
OA
IC
Conserver Efficiency CE
CE =
SE
NE
– BE =
IA
OA
– BE = DE – BE
(continued)
84096_APPX_Chatburn.indd 233 6/18/10 8:30:53 AM
234  Appendix Reference Data
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84096_APPX_Chatburn.indd 234 6/18/10 8:30:54 AM
Translation of Commonly Used Words  235
translation oF CoMMonly used Words ■
Table A–23 French Words
English French
Approximate Phonetic
Pronunciation
Baby Bébé BayBay
Bed Lit Lee
Blood Sang Sahng
Breath Souffle Sufl
Breathe Respirer Respeer9ay
Cannula Canule Ka9nuel
Chest Thoracique Thora9seek
Cough (n) Toux Too
Deep Profond Profond9
Disease Maladie Maladee
Doctor Docteur Dock9tœr
Down En bas Abn9bah
Family Famille Fahm9eeyuh
Fast Rapide Rah9peed
Head Tête Teht
Heart Coeur Ker
Hood Coiffe Kwaff
In En Ahn
Intensive Care Unit Unite de Soins Intensifs Uni9tay duh Swähnzan
tawnzeef
Lay Poser Pozay
Left Gauche Gosh
Listen to Écouter Aycoo9tay
Lungs Poumon Poo9mahn
Mask Masque Mahsk
Mechanical ventilation Respiration assistee Rehspeerahseeawn ah
see9stay
Medication Médication Maydee9cahseeawn
(continued)
84096_APPX_Chatburn.indd 235 6/18/10 8:30:54 AM
236  Appendix Reference Data
Table A–23 French Words (continued)
English French
Approximate Phonetic
Pronunciation
Mist Brume Bruem
Mouth Bouche Boosh
Mucous Mucus Mew9kus
Name Nom Noh
Needle Aiguille Ay9geeyah
No Non Noh
No smoking Défense de fumer Duh9fonce duh foo9may
Normal Normal Normal
Nose Nez Nay
Nurse (female) Infirmière An9firmee9air
Out Hors Or
Oxygen Oxygène Oxy9jehn
Oxygen tent Tente à oxygene Tahnt9à oxy9jehn
Pain Douleur Doo9lure
Patient Patient Pa9seeahn
Position Position Pozee9seeon
Pulse Pouls Pool
Relaxation Relâchement Reh9lashmon
Rest Repos Reh9po
Respiratory therapist Spécialiste de thérapie
respiratoire
Spay9syaleest duh téra
pee reh9speerahtwahr9
Ribs Côtes Coat
Right Droit Drah
Sit S9asseoir Sahs9swahr
Sleep Sommeil So9mayuh
Slow Lent Lawn
Smoking Fumer Foo9may
Stomach Estomac Ehstome9ah
Stop Arrêter Ahreh9tay
Take Prendre Prawn9druh
84096_APPX_Chatburn.indd 236 6/18/10 8:30:54 AM
Translation of Commonly Used Words  237
Table A–23 French Words (continued)
English French
Approximate Phonetic
Pronunciation
Tent Tente Tawn9tuh
Tube Tube Tueb
Turn Tourner Toor9nay
Understand Comprendre Comprawn9druh
Up En haut Onoh9
Yes Oui Wee
Table A–24 Spanish Words
English Spanish Phonetic Pronunciation
Baby Bebe Baybay
Bed Cama Cahma
Blood Sangre Sangray
Breath Aliento Alee9entoe
Cannula Canula Khanula
Chest Pecho 9Paycho
Cold Resfrio Res9freeo
Cough (n) Tos Tos
Deep Hondo 9Awndoe
Disease Enfermedad 9Ennfurmay9dodd
Doctor Doctor Dock9tore
Down Bajo 9Baho
Family Familia Fam9eeleeah
Fast Rapido 9RRahpeadoe
Head Cabeza Ca9bessa
Heart Corazón Cora9sone
Hood Caja 9Caha
In Adentro All9thentro
Intensive Care Unit Unidad de Tratamiento
Intensivo
Uni9thad day Trata9mien
toe Inten9seevoe
Lay Acostarse Allcoe9starsay
(continued)
84096_APPX_Chatburn.indd 237 6/18/10 8:30:54 AM
238  Appendix Reference Data
Table A–24 Spanish Words (continued)
English Spanish Phonetic Pronunciation
Left Izquierda Iskey9airda
Listen to Escuchar Escoo9char
Lungs Pulmon Pool9mun
Mask Mascara 9Mascarah
Mechanical ventilation Respiración mecánica Respearahsee9own
mhe9khaneeca
Medication Medicina Medee9seena
Mist Vapor Vah9poor
Mouth Boca 9Boka
Mucous Moco 9Moekoe
Name Nombre 9Nomebray
Needle Aguja Ah9gooha
No No No
No smoking Prohibido fumar Pro9eebay fu9mar
Normal Normal Nor9mal
Nose Nariz Nar9eese
Nurse (female) Enfermera Ennfur9mayrah
Out Fuera Ah9fwayra
Oxygen Oxigeno Awk9seehayno
Oxygen tent Tienda para oxigenación Tea9enda para awk9see
hayno
Pain Dolor Doe9lore
Patient Paciente Pasee9entay
Position Posición Po9seeseeown
Pulse Pulso 9Poolso
Relaxation Descanso Des9khanso
Rest Reposo Re9poso
Respiratory therapist Terapista de respiración Tayrah9peesta day
respeerasee9own
Ribs Costillas Kos9teeyas
Right Derecho Day9raycho
84096_APPX_Chatburn.indd 238 6/18/10 8:30:54 AM
Translation of Commonly Used Words  239
Table A–24 Spanish Words (continued)
English Spanish Phonetic Pronunciation
Roll over Darse la vuelta 9Darsay la boo9ellta
Sit Sentarse Sen9tarsay
Sleep Dormir Door9mear
Slow Despacio Des9paseeo
Smoking Fumar Fu9mar
Stomach Estómago Ex9toemago
Stop Alto 9Ahltoe
Take Tomar Toe9mar
Tent Tienda Tea9enda
Tube Tubo 9Toobow
Turn Vuelta Boo9ellta
Understand Entender Enten9dair
Up Arriba Are9reeba
Yes Si See
Table A–25 Italian Words
English Italian
Approximate Phonetic
Pronunciation
Baby Bambino Bahmbee9noe
Bed Letto Leh9toe
Blood Sangue Sahn9gway
Breath Fiato Feeah9toe
Cannula Cannula Cahn9noola
Chest Torace Tohrah9chay
Cough Tosse Toss9say
Deep Profondo Prohfon9doh
Disease Affezione AfettsseeOh9nay
Doctor Dottore Dohtor9ray
Down Giu Jew
Family Famiglia Fahmee9leeyah
Fast Fermo Fair9mo
(continued)
84096_APPX_Chatburn.indd 239 6/18/10 8:30:54 AM
240  Appendix Reference Data
Table A–25 Italian Words (continued)
English Italian
Approximate Phonetic
Pronunciation
Head Testa Test9ah
Heart Cuore Kwoh9ray
Hood Cappuccio Cappoo9cheeo
In Entro Ehn9troe
Intensive Care Unit Unita di trattamento
intensivo
Oonittah di trahtah
mehn9toe Eenten9seevoh
Lay Posare Poesah9ray
Left Sinistro Sihnee9stroe
Listen to Ascoltare Ahskohltah9ray
Lungs Polmone Polemoan9ay
Mask Maschera Mahskeh9rah
Mechanical ventilation Respirazione assistita Rehspeerahtsee9owenay
ah9seesteetah
Medicine Medicina Mehdihchee9nah
Mist Nebbia Neh9beeyah
Mouth Bocca Bock9kah
Mucous Muco Moo9koh
Name Nome No9may
Needle Ago Ah9goe
No No No
No smoking Vietato fumare Veeehtah9toe foomah9
ray
Normal Normale Normah9lay
Nose Naso Nah9soe
Nurse (female) Infermiera Eenfairmeeay9rah
Out Fuon Foooh9ree
Oxygen Ossigeno Ohsee9jehnoe
84096_APPX_Chatburn.indd 240 6/18/10 8:30:54 AM
Translation of Commonly Used Words  241
Table A–25 Italian Words (continued)
English Italian
Approximate Phonetic
Pronunciation
Oxygen tent Tenda per ossigeno 9Tehndah pair ohsee
9jaynoh
Pain Dolore Doeloe9ray
Patient Paziente Pahtseeen9tay
Pill Pillola Peel9lohlah
Position Posizione Pohzeetseeoh9nay
Pulse Polso Pole9soe
Relaxation Rilassamento Reelah9sahmen9toh
Rest Riposo Reepoe9so
Ribs Coste Coe9stay
Right Destra Deh9strah
Roll over Rivoltate Reevoltah9tay
Sit Sedere Sayday9ray
Sleep Sonno Sonn9noh
Slow Lento Lehn9toe
Smoking Fumare Foomah9ray
Stomach Stomaco Stoe9mahcoe
Stop Arrestare Ahrresstah9ray
Take Prendere Prehndeh9ray
Tent Tenda Tehn9dah
Tube Tubo Tube9oh
Turn Voltare Volltab9ray
Understand Intendere Eenten9dayray
Up Su Soo
Yes Si See
84096_APPX_Chatburn.indd 241 6/18/10 8:30:54 AM
242  Appendix Reference Data
Table A–26 Polish Words
English Polish Phonetic Pronunciation
Baby Babe Baabe
Bed Lozko Wooshko
Blood Krew Krrev
Breath Dech Deh
Breathe Oddychac Awddehhach
Chest Skrzunic Kshooneats
Cough Kaszel Kashell
Deep Gleboki Gwembokey
Doctor Dohor Doktore
Down Dolle Doughleh
Family Rodzine Rogeena
Fast Szybki Shipkee
Head Glowa Gwova
Heart Serce Seltze
Hood Kaptur Koptour
In Wewnatrz Vevnoonch
Lay down Skladac Squaqdatch
Lay on Nakladac Nawquadach
Left Lewy Levy
Listen to Kogos Kogush
Lungs Pluco Pwutzo
Mask Maska Mawska
Medicine Medycyna Medetsina
Mist Mgla Mehgwa
Mouth Usta Uhstah
Needle Igla EEgwan
No Nie Nyeh
No smoking Nie wolno palic Nyeh volno paleech
Normal Normalny Nanmawlne
(continued)
84096_APPX_Chatburn.indd 242 6/18/10 8:30:55 AM
Translation of Commonly Used Words  243
Table A–26 Polish Words (continued)
English Polish Phonetic Pronunciation
Nose Nos Noss
Nurse Nianka Kneeyanka
Out Na zew natrz Na Zev Nunch
Oxygen Tlen Telen
Pain Bol Bole
Patient Cierpliwy Cherpleavy
Position Posada Pawsada
Pulse Puls Pulls
Relaxation Oslabienie Oswabeeyenye
Respiratory therapist Oddechowy terapia Awddehhovy terrawpeaa
Rib Zebra Zehbra
Right Prawy Prahvy
Roll over Odwrocic Owdlvucheech
Sit Siedziec Shehjetch
Sleep Spac Spahch
Slow Powolny Povolne
Smoker Palacz Palech
Stomach Zoladek Zawwondeck
Stop Zatkac Katch
Take Brac Bratch
Tent Namlot Nemwatt
Tube Rura Rurah
Turn Vi obracac Vee Obrahchatch
Understand Rozumiec Rohzoommeech
Up Gorze Goozech
Yes Tak Tuk
84096_APPX_Chatburn.indd 243 6/18/10 8:30:55 AM
244  Appendix Reference Data
Table A–26 German Words
English German Phonetic Pronunciation
Baby Baby Baabe
Bed Bett Bet
Blood Blut Bloot
Breath Atem Ah9tem
Breathe Atmen Aht9men
Cannula Kanüle Kahn9oohluh
Chest Brust Broost
Cough Husten Hoo9stun
Deep Tief Teef
Disease übel Ooh9buhl
Doctor Doktor Dock9tohr
Down Nieder nee9der
Family Familie Fah9meelyah
Fast Fest Fest
Head Kopf Cawpf
Heart Herz Hairts
In In In
Intensive Care Unit Intensivstation Inten9siv9stahts9eeohn
Lay Legen Lay9gehn
Left Links Lihnks
Listen to Hören 9Hœren
Lungs Lunge Luhn9guh
Mask Maske 9Mahskuh
Mechanical ventilation Assistielte atmung Assissteer9the aht9moong
Medication Arznei Arts9nye
Mouth Mund Moont
Mucous Schleim Shlime
Name Name Nahm9uh
Needle Nadel Nah9dul
84096_APPX_Chatburn.indd 244 6/18/10 8:30:55 AM
Translation of Commonly Used Words  245
Table A–26 German Words (continued)
English German Phonetic Pronunciation
No Nein Nine
No smoking Rauchen verboten rou9khen fairboh9ten
Normal Normal Normal9
Nose Nase Nah9suh
Nurse Kraukenschwester Krahnkenschwehst9er
Out Aus Ows
Oxygen Sauerstoff Zou9er shtoff
Oxygen tent Sauerstoffzelt Zou9ershtoff9tsehlt
Pain Schmerz Shmairts
Patient Patient Patsi9ent
Position Stellung Shtehl9oong
Pulse Puls Pools
Relaxation Entspannung Ehntspah9noong
Rest Pause Pou9suh
Ribs Rippen Rih9pehn
Right Recht Rehkt
Sit Sitzen Zit9sen
Sleep Schlaf Shlahf
Slow Nachgehen Nahkh9gayehn
Smoking Rauchen Rou9khen
Stomach Magen Mah9gehn
Stop Halten Hahl9ten
Take Nehmen Nay9men
Tent Zelt Tselt
Tube Rohr Roar
Turn Wenden Ven9den
Understand Verstehen Fairstay9en
Up Auf Ouf
Yes Ja Yah
84096_APPX_Chatburn.indd 245 6/18/10 8:30:55 AM
246  Appendix Reference Data
Postural drainage Positions ■
Figure A–1 Upper lobes, apical segment. Patient sits and leans back on a pillow at a
30degree angle against the therapist. Clap between the clavicle and the top of the
scapula on each side.
Figure A–2 Upper lobes, anterior segment. Patient lies on his back with knees flexed.
Clap between the clavicle and nipple on each side.
84096_APPX_Chatburn.indd 246 6/18/10 8:30:55 AM
Postural Drainage Positions  247
Figure A–3 Upper lobes, posterior segment. Patient leans forward over a folded pillow
at a 30degree angle. Clap over the upper back on both sides.
Figure A–4 Right middle lobe, lateral segment; medial segment. Bed is elevated 14 in.
(about 15 degrees). The patient lies head down on the left side and rotates one quarter
turn backward. The knees should be flexed. Clap over the right nipple. In females with
breast development or tenderness, use cupped hand with heel of hand under armpit
and fingers extending forward beneath the breast.
84096_APPX_Chatburn.indd 247 6/18/10 8:30:56 AM
248  Appendix Reference Data
Figure A–5 Lingular segment, left upper lobe, superior segment, inferior segment.
Patient in a headdown position on the right side and rotated one quarter turn back
ward. Clap over the left nipple.
Figure A–6 Lower lobes, superior segment. Patient lies on abdomen with two pillows
under the hips. Clap over the middle part of the back at the tip of the scapula on either
side of the spine.
84096_APPX_Chatburn.indd 248 6/18/10 8:30:56 AM
Postural Drainage Positions  249
Figure A–7 Lower lobes, anterior basal segments. The foot of the bed is elevated 18 in.
(about 30 degrees). The patient lies on his side with a pillow between the knees. Clap
over the lower ribs just beneath the axilla.
Figure A–8 Lower lobes, lateral basal segments. The foot of the bed is elevated 18 in.
(approximately 30 degrees). The patient lies on his abdomen, head down, and rotates
one quarter turn upward from a prone position. The upper leg is flexed over a pillow
for support. Clap over the uppermost portion of the lower ribs.
84096_APPX_Chatburn.indd 249 6/18/10 8:30:56 AM
250  Appendix Reference Data
Figure A–9 Lower lobes. posterior basal segments. The foot of the bed is elevated 18
in. (about 30 degrees). The patient lies on his abdomen, head down, with a pillow under
the hips. Clap over the lower ribs close to the spine on each side.
Figure A–10 Positions for chest physiotherapy. (1) The anterior segment of the upper
lobes is drained in a supine position at a 30degree upright angle. (2) Drain the apical
segment of the right lung while the infant lies on his left side at a 30degree upright
angle. (3) The posterior segment of the right upper lobe is drained in a prone position
with the right side elevated 45 degrees. (4) Drain the anterior segment of the upper
lobe in a supine position.
1 2
4 5
3
84096_APPX_Chatburn.indd 250 6/18/10 8:30:57 AM
Postural Drainage Positions  251
Figure A–11 (1) The right middle lobe is drained at a 15degree, headdown angle,
with a 45degree rotation to the left. To drain the lingula, rotate to the right. (2) The
superior segments of the lower lobes drain in a prone position. (3) Drain the anterior
basal segments of the lower lobes at a 30degree, headdown position. (4) The basal
segments of the lower lobe are drained at a 30degree, headdown position while the
infant is lying on his side. (5) The posterior basal segments of the lower lobes are
drained at a 30degree, headdown prone position.
1 2
4 5
3
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Intentional Blank 252
84096_APPX_Chatburn.indd 252 6/18/10 8:30:57 AM
INDEX
INDEX
Note: Italicized page locators indicate a
figure; tables are noted with a t.
A
Abbreviated Injury Scale score, 5
Abbreviations, commonly used, 210
Absolute humidity, equation for, 109
Acceleration, units of, 206
Acetic acid, capabilities of, in respira
tory care, 232t
Acidbase disorders
classification of, based on Stewart
independent variables, 83
Stewart approach to, 81–82
Traditional approach, 75
Activities, common, oxygen consump
tion for, 43, 43t
Acute Physiology and Chronic Health
Evaluation. See APACHE II
score
Acute respiratory distress syndrome,
defined, 21
Adaptive control, targeting schemes,
161
Adaptive Support Ventilation, 161
Addition
of fractions with different denomina
tors, 172
of fractions with same denominator,
171
in scientific notation, 175
Addition rule, probability, 188
Adults, acidbase map for, 77
Aerosol deposition, physical factors in,
221t
Aerosol particles, deposition of (mouth
breathing), 221t
Airway conductance (Gaw)
defined, 38
prediction equations for, 38t
Airway dimensions, from birth to adult,
231t
Airway obstruction, helium therapy
and, 118
Airway opening, 133
Airway resistance (Raw), 150
conversion factors for, 203t
defined, 38
prediction equations for, 38t
Airways, 128–132, 133
appropriate suction settings vacuum
settings for, 132t
approximate equivalents of various
endotracheal tube sizing meth
ods, 130–131t
approximate equivalents of various
tracheostomy tubes, 128t
dimensions of cuffless pediatric tra
cheostomy tubes, 129t
dimensions of lowpressure cuffed
adult tracheostomy tubes,
129–130t
guide to choice of endotracheal
tubes, 131t
laryngoscope blades, 130t
oral, dimensions of, 128t
AIS score. See Abbreviated Injury Scale
score
Alcohols, capabilities of, in respiratory
care, 232t
84096_INDX_Chatburn.indd 253 6/18/10 8:28:15 AM
254  Index
Altitude
Denver and Mt. Everest, comparison
of bloodgas values at sea level
and, 53t
effect of, on inspired, alveolar, and
arterial oxygen tension, 55
effect of, on inspired oxygen tension,
52t
effect of, on Pao
2
during oxygen
administration, 56
effect of, on trapped gas, 101t
Alveolararterial oxygen tension gradi
ent, 60–62
abbreviation, units, and normal value
for, 60
assessment of hypoxemia in adults
and children, 62t
assessment of hypoxemia in newborn
and elderly patients, 62t
normal, prediction equations for,
while breathing room air, 61
prediction equations for determining
oxygenation impairment for
sitting subjects, 61t
Alveolar carbon dioxide equation, 50
Alveolar dimensions, from birth to
adult, 231t
Alveolar oxygen tension
altitude’s effect on, 55
mean, equation for, 56–57
nomogram of equation for, 57
Alveolar pressure, 154
above set PEEP, 163
Alveolar ventilation 1V
#
A2
calculating, 32, 137
defined, 137
typical values for, 33t
Amount of substance
base unit of SI, 199t
conversion factors for, 202t
in respiratory physiology, 205
Ampere, 199t, 203
Angles, generating, 187
Angular measure systems, in trigonom
etry, 186
Anion gap, 78–79
abbreviation, units, normal value for,
78
equations for, 78–79
function of, 78
Antilogarithm (antilog), 184
Antoine equation, 110–112
data, 111t
uses for, 110
water vapor pressure, content, and
percent saturation, 111–112t
water vapor pressure and content as
function of temperature from,
112
APACHE article (original), scores used
in, 3
APACHE II score, 6
diagnostic categories weight leading
to ICU admission, 9–10t
severity of illness scored with, 7–8t
Apgar score, 17t
interpretation of, 17
observations related to, 16
Apothecary system, measurement units
in, 220t
ARDS. See Acute respiratory distress
syndrome
Area
conversion factors for, 202t
currently accepted nonSI units, 201t
representative derived units, 199t
Arterialalveolar oxygen tension ratio
abbreviation, units, and normal value
for, 58
graph relating expected Pao
2
during
oxygen administration based
on measured Pao
2
of room air,
58
nomogram for, 59
prediction for normal, while breath
ing room air, 60
84096_INDX_Chatburn.indd 254 6/18/10 8:28:15 AM
Index  255
Arterial oxygen tension, altitude’s effect
on, 55
Arteriovenous oxygen content difference
abbreviation, units, normal value for,
66–67
equation for, 67
Assisted breath, mechanical ventilation
and, 157
Association for the Advancement of
Automotive Medicine, 5
Associative axiom, 168
Atmospheric content, percent by vol
ume, 125t
Atomic weight, 217
ATPD (ambient temperature and pres
sure, dry), 123t
ATPS (ambient temperature and pres
sure, saturated with water
vapor), 123t
Average, 190
Avogadro’s law, 103–104
derivation of density of gas and,
103–104
equations for, 103
Avoirdupois system, measurement units
in, 220t
B
Base, 174
Base excess
abbreviation, units, normal value for,
80
defined, 80
equations for, 80–81
Bernoulli theorem, 106
Bicarbonate ion formulation equilib
rium, equation for, 81–82
BiPAP, 161
Blender system equations, 113–114
Blood
oxygen content of, 65–66
whole, components of carbon dioxide
curve for, 78
Bloodgas analysis, 73–83
anion gap, 78–79
base excess, 80–81
deltadelta gap, 79–80
HendersonHasselbalch equation, 73
Stewart approach to acidbase disor
ders, 81–82
strong ion difference, 82
strong ion gap, 83
Bloodgas measurements, 216
Bloodoxygen dissociation computation,
equations for, 70–71
Body conditions
converting gas volumes from room
temperature to, combined gas
law and, 98–99
Body surface area
average, to age, weight, and height,
226t
pediatric chart, 227t
prediction equations for, 227t
Body temperature and pressure, satu
rated, 205
Boyle’s law, 99–101
effect of altitude on trapped gas and,
101t
examples of, 100
Brain hypoxia, oxygen availability and,
92
Breathing cycles, 144
Breathing frequency
defined, 144
Breaths
assisted, 157
loaded, 157
mandatory, 159, 160
mode of mechanical ventilation and,
156–157
spontaneous, 159, 160
unassisted, 157
Breath sequences
categories of, 159–160
defined, 159
84096_INDX_Chatburn.indd 255 6/18/10 8:28:15 AM
256  Index
Bronchial inhalation challenges, 41–42,
41t, 42t
Bronchopulmonary anatomy, compara
tive nomenclature of, 229–230t
Bronchus, dimensions from birth to
adult, 231t
BSA. See Body surface area
BTPS. See Body temperature and pres
sure, saturated
BTPS (body temperature and ambient
pressure, saturated with water
vapor at body temperature),
123t
Buffer solutions, defined, 217
Bunsen solubility coefficients, 107t
for oxygen in blood, 69
C
Calibration factor, of flowmeter, 118
Calories, approximate daily require
ments for, 232t
Candela, 199t, 204
Capacitance coefficient, 208
Capsules, calculating dosages from,
218
Carbonate ion formation equilibrium,
equation for, 81–82
Carbon dioxide output
defined, 49
equation for, 49
rebreathing experiments or confine
ment in enclosed area, equation
for, 49–50
Carbon monoxide diffusing capacity
defined, 39
prediction equations for, 39t
Cardiac disease, patterns of response to
exercise with, 44t
Cardiac index, 84–85
equation, units, normal value for, 85
use for, 84
Cardiac output
abbreviation, unit, normal value for,
84
arteriovenous oxygen content differ
ence and, 66
defined, 84
equation for, 84
Cardiopulmonary stress tests, Vo
2
peak
measurement for, 42–43
Cartesian plane, 178
Cathecholamine index, 21
Catheters, conversion table for, 225t
Caucasians, lung function values for, 32
Celsius scale, 208
Celsius temperature, Fahrenheit inter
conversions with, 222t
Centimetergramsecond measurement
system, 88, 207
Central venous pressure, 86–87
abbreviation, units, normal value for,
86
hemodynamic parameters for, 87t
Cerebral perfusion pressure
abbreviation, units, normal value for,
90
equation for, 90
CGS measurement system. See
Centimetergramsecond mea
surement system
Characteristic, of logarithm, 183
Charles’s law, 101–102
equations for, 101
examples, 101–102
Charlson Comorbidity Index, 2
Chest physiotherapy positions, 250–251
Chest wall, 133
Children. See also Infants; Neonates
acidbase map for, 77
hypotension in, 19
hypoxemia assessment in, 62t
CL. See Lung compliance
Clinical Pulmonary Infection Score,
24, 24t
CMV. See Continuous mandatory ven
tilation
Coefficients
in quadratic equation, 181
84096_INDX_Chatburn.indd 256 6/18/10 8:28:15 AM
Index  257
in scientific notation, 174
Combined gas law, equation for, 98
Common logarithms, 182
rules of, 182–183t
Communityacquired pneumonia,
defined, 23
Commutative axiom, 168
Compliance, 163
calculated, 138
for chest wall, equation for, 138–139
conversion factors for, 202t
defined, 138
dynamic, 140
of lung, defined, 138
patient circuit, computing, 139
in respiratory physiology, 208
specific, 152
static, 140
static respiratory system, equation
for, 140
Compressed gas, calculating duration of
flow from cylinder of, 117–118
Compressed volume, calculating, 152
Compressor, defined, 141
Conductance, 208
Conservation of mass A, equation,
81–82
Constant of proportionality, 179
Continuous mandatory ventilation, 159
Continuous spontaneous ventilation, 160
Control variable, mechanical ventilation
and, 157
Conversion equivalents, liquid and
weight, 220–221t
Conversion factors, for units commonly
used in medicine, 202–203t
Converting gas volumes from,
combined gas law and, 98–99
Coronary perfusion pressure, equation
for, 90
Corrected standard base excess, 80
Correlation coefficient (Pearson r),
191–192
Cosecant, 187
Cosine, 187
Cotangent, 187
CSV. See Continuous spontaneous ven
tilation
Cuffed adult tracheostomy tubes,
lowpressure, dimensions of,
129–130t
Cuffless pediatric tracheostomy tubes,
dimensions of, 129t
C/Vl. See Specific compliance
CVP. See Central venous pressure
Cycle, defined, 141
Cycle variable, mechanical ventilation
and, 158
Cylinder flow, K factors (L/psi) to cal
culate duration of, 119t
D
Dalton’s law of partial pressures, 104
Dead space volume (Vd)
clinical calculation of, 65
defined, 141
typical values for, 33t
Decimal multiples and submultiples,
prefixes and symbols for, 199t
Deep venous thrombosis
Wells score for
modified score, 29
original score, 28–29
pulmonary embolism and, 26
Degrees
radians and, 186
in trigonometry, 186
Deltadelta gap, 79–80
abbreviation, units, normal value for,
79
equation for, 80
function of, 79
Denominator, 169
Denver, comparison of bloodgas values
at sea level and altitude in, 53t
Dependent variable, 178
Detergents, capabilities of, in respiratory
care, 232t
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258  Index
Diameter index safety system, represen
tative, components of, 122
Difficult weaning, mechanical ventila
tion, defined, 26
Diffusing capacity of lung expressed as
volume, 212
Disinfecting agents, capabilities of, in
respiratory care, 232t
Distributive axiom, 168
Division
of fractions, 170–171
in scientific notation, 175
DLco. See Carbon monoxide diffusing
capacity
Drug dosage calculations
from percentstrength solutions,
218–219
from stock solutions, tablets, or cap
sules, 218
Dual control, targeting schemes, 161
Duty cycle, defined, 141–142
DVT. See Deep venous thrombosis
Dynamic characteristic, dynamic com
pliance vs., 140–141
Dynamic compliance
defined, 140
E
ECMO. See Extracorporeal membrane
oxygenation
Elastance (E), 142, 208
Elderly patients, hypoxemia assessment
in, 62t
Electrical charge equation, 81–82
Electric current, base unit of SI, 199t
Endexpiratory alveolar pressure or
autoPEEP, 163
Endotracheal tubes
guide to choice of, 131t
infants, determining appropriate
length of insertion for, 132
sizing methods, approximate equiva
lents of, 130–131t
Energy expenditure, average rates of, for
men and women, in U.S., 42t
Entrainment system equations, 113–114
Equation of motion
defined, 142
equations for, 142–143
Equations
linear, 179–180
quadratic, 180–181
Equivalent weight
defined, 217
of serum calcium, 204
Ethnicity, lung function values and, 32
Ethylene oxide, capabilities of, in respi
ratory care, 232t
Exercise, patterns of response to, 44t
Exercise physiology, 42–45
maximum heart rate, 45
maximum oxygen consumption,
42–43
maximum oxygen pulse, 45
resting energy expenditure, 42
Expiration, mathematical models of
pressurecontrolled mechanical
ventilation and, 164
Expiratory resistance, 163
Expiratory time, 143–144, 163
calculating, 143–144
defined, 143
Expiratory time constant, 163
Expired, symbol for, 212
Exponents, 174
rules for, 174t
in scientific notation, 174
Extracorporeal membrane oxygenation,
oxygenation index and, 63
F
Factorial notation(!), 189
Fahrenheit temperature, Celsius inter
conversions with, 222t
Failed spontaneous breathing, mechani
cal ventilation, defined, 26
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Index  259
Falsenegative rate, defined, 196
Falsepositive rate, defined, 196
Females, oxygen consumption as func
tion of age and heart rate for,
94t
FEV
1
. See Forced expiratory volume in
1 second
FEV/FVC. See Forced expiratory vol
umeforced vital capacity ratio
Fick principle, 84
Fick’s law of diffusion, equation for,
108
Flow resistance, 150–151
Force
conversion factors for, 202t
representative derived units, 199t
in respiratory physiology, 206
Forced expiratory flow, related to some
portion of FVC curve, 212
Forced expiratory flow 25%–75%
(FEF
25%–75%
), 37
defined, 37
prediction equations for, 37t
Forced expiratory volumeforced vital
capacity ratio
defined, 36
prediction for mean normal FEV
1
/
FVC ratio (%), 37t
Forced expiratory volume in 1 second
defined, 36
prediction equations for, 36t
Forced vital capacity
defined, 36
prediction equations for, 36t
Fractional concentration of carbon diox
ide in expired gas, 216
Fractional concentration of oxygen, 216
Fractions, 169–172
addition and subtraction of, with dif
ferent denominators, 172
addition and subtraction of, with
same denominator, 171
division of, 170–171
for generating random numbers, 198
multiplication of, 170
multiplication property of, 169–170
FRC. See Functional residual capacity
French words, commonly used, transla
tion of, 235–237t
Frequency
breathing, defined, 144
breaths/min, 163
representative derived units, 199t
ventilator, defined, 144
ventilator (as related to gas
exchange), defined, 144
Fio
2
, approximate, derivation for low
flow oxygen system, 114–117
Functional residual capacity, 143
defined, 34
prediction equations for, 34t
typical values for, 34t
Functions, 176–180
defined, 178
graphic representation of, 178
linear, 178–179
FVC. See Forced vital capacity
G
Gas cylinders, 117–125
duration of, 117–118
helium therapy, 118
working tables and figures, 119–121
approximate number of hours of
flow, 119t
atmospheric content, percent by
volume, 125t
conversion figures to correct
volume (ATPS) to volume
(BTPS), 124t
effects of breathing oxygen during
hyperbaric therapy, 125t
gas volume correction equations,
123t
K factors (L/psi) to calculate dura
tion of cylinder flow, 119t
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260  Index
medical gas cylinder color codes,
119t
medical gas cylinder dimensions,
120t
medical gas cylinder specifica
tions, 120t
new standard threaded valve
outlet connections for medical
gases, 121t
physical characteristics of gases,
125t
PPLT index, CGA standard, 122
schematic illustration of compo
nents of representative diam
eter index safety system, 122
Gas diffusion, conversion factors for,
203t
Gases
ideal, behavior of, 98
physical characteristics of, 125t
Gas exchange, 48–73
alveolararterial oxygen tension gra
dient, 60–62
alveolar carbon dioxide equation, 50
alveolar oxygen tensions, 56–57
arterialalveolar oxygen tension ratio,
58–60
arteriovenous oxygen content differ
ence, 66–67
carbon dioxide output, 49–50
clinical calculation of dead space, 65
equations for human bloodoxygen
dissociation computation,
70–71
hemoglobin affinity for oxygen, 71
oxygenation index, 63
oxygenation ratio, 62
oxygen content of blood, 65–66
oxygen uptake, 48
partial pressure of inspired oxygen,
51–52
physiologic dead space (Bohr equa
tion), 63–64
respiratory exchange ratio, 51
respiratory quotient, 50–51
venoustoarterial shunt (classic
form), 68
venoustoarterial shunt (clinical
form), 68–69
ventilationperfusion ratio, 67
ventilator frequency related to, 144
Gas laws, special, 99–112
absolute humidity, 109
Antoine equation, 110–112
Avogadro’s law, 103–104
Bernoulli theorem, 106
Boyle’s law, 99–101
Charles’s law, 101–102
Dalton’s law of partial pressures, 104
Fick’s law of diffusion, 108
GayLussac’s law, 102–103
GoffGratch equation, 110, 110t
Graham’s law, 107
Henry’s law, 106–107
Law of Laplace, 108–109
Poiseuille’s law, 104–105
relative humidity, 109
Reynold’s number, 105–106
Gas transport, conversion factors for,
203t
Gas volume correction equations, 123t
Gauge pressure, defined, 145
General gas law, 98–99
General linear equation, 179
German words, commonly used, transla
tion of, 244–245t
Glasgow Coma Scale, 3
Glutaraldehydes, capabilities of, in
respiratory care, 232t
Gram
metric system, 206
Gramforce, 206
Gram molecular weight, defined, 217
H
Healthcareassociated pneumonia,
defined, 23
Heart rate reserve, defined, 45
84096_INDX_Chatburn.indd 260 6/18/10 8:28:15 AM
Index  261
Height, Metropolitan Life Insurance
(1983) height and weight
tables, 228–229t
Helium, characteristics of, 118
Helium therapy, 118
Hemodynamics, 84–95
cardiac index, 84–85
cardiac output, 84
central venous pressure, 86–87
cerebral perfusion pressure, 90
coronary perfusion pressure, 90
mean arterial pressure, 86
oxygen availability (delivery), 92
oxygen consumption, 92–94
oxygen extraction ratio, 94–95
pulmonary vascular resistance index,
89
stroke index, 85–86
stroke volume, 85
stroke work, 90–92
left ventricular stroke work index,
90–91
right cardiac work index, 92
right ventricular stroke work
index, 91
systemic vascular resistance, 88–89
vascular resistance, 87–88
Hemodynamic variables, 2001 expanded
criteria for sepsis and, 20
Hemoglobin affinity for oxygen, 71–73
factors shifting curve, 71
nomogram relating Po
2
and oxygen
saturation, 72
oxyhemoglobin dissociation curves,
73
HendersonHasselbalch equation,
73–74
acidbase interpretation scheme, flow
chart, 76
acidbase map for children and
adults, 77
acidbase map for neonates, 77
components of carbon dioxide curve
for whole blood, 78
expected compensation for simple
acidbase disorders, 75t
function of, 73
modified SiggaardAnderson nomo
gram relating blood pH, bicar
bonate concentration and Pco
2
,
76
ranges and nomenclature for pH and
Paco
2
, 74t
rearrangement of, 74
Henry’s law (Law of solubility), 106–
107, 208
Bunsen solubility coefficients, 107t
equations for, 107
Hertz (Hz), 199t
Hex nut, diameter index safety system,
122
Home care ventilator, blender and
entrainment system equations
and, 113–114
Hospitalacquired pneumonia, defined,
23
Hospital mortality, Simplified Acute
Physiology Score, 12–13t
Hot water, capabilities of, in respiratory
care, 232t
HRmax. See Maximum heart rate
HRR. See Heart rate reserve
Humidity
absolute, 109
relative, 109
Hydrogen peroxidebased compounds,
capabilities of, in respiratory
care, 232t
Hyperbaric therapy, effects of breathing
oxygen during, 125t
Hypodermic needle tubing, conversion
table for, 226t
Hypotension, 19
Hypoxemia
assessment of, in adults and children,
62t
assessment of, in newborn and elder
ly patients, 62t
84096_INDX_Chatburn.indd 261 6/18/10 8:28:15 AM
262  Index
I
ICU admission, diagnostic categories
weight leading to, 9–10t
Ideal gas equation, absolute humidity
equation derived from, 109
Ideal gas law, equation for, 98
IMV. See Intermittent mandatory ven
tilation
Incubator temperatures, according to
age, 231t
Independent variable, 178
Infant endotracheal tubes, determining
appropriate length of insertion
for, 132
Infants
Apgar score for, postdelivery,
16–17, 17t
assessing, before treatment with
extracorporeal membrane oxy
genation, 63
chest physiotherapy positions for,
250–251
Infection, defined, 19, 20
expanded criteria for sepsis and,
20
Injury Severity Score, 5
Inotropic score, 21
Inspiration
defined, 145
mathematical models of pressure
controlled mechanical ventila
tion and, 164
Inspiratory:expiratory time ratio
defined, 145
equation for, 145
Inspiratory flow
calculating, 145
defined, 145
Inspiratory hold, defined, 146
Inspiratory hold maneuver, tidal volume
and, equation for, 152
Inspiratory relief valve, defined, 146
Inspiratory resistance, 163
Inspiratory time, 163
defined, 146
Inspiratory time constant, 163
Inspiratory time fraction, 163
Inspiratory triggering flow, defined, 147
Inspiratory triggering pressure, defined,
147
Inspiratory triggering response time,
defined, 147
Inspiratory triggering volume, 147
Inspiratory vital capacity, 33
Inspiratory work per breath, 163
Inspired, symbol for, 213
Inspired oxygen concentration, 117
as function of oxygen flow rates and
mixed air, 116–117
Inspired oxygen tension, altitude’s effect
on, 52t, 55
Intelligent control, targeting schemes,
161
Intermittent mandatory ventilation,
159–160
International System of Units, 199
Interstitial lung disease, exercise
response patterns with, 44t
Intrapulmonary shunting, alveolararte
rial oxygen tension gradient
and, 60–61
Intubation Difficulty Scale, 26, 27t
Isotonic solutions, defined, 217
ISS. See Injury Severity Score
Italian words, commonly used, transla
tion of, 239–241t
IVC. See Inspiratory vital capacity
J
Joule (J), 199t, 207
K
Kelvin (K), 208
base unit of SI, 199t
defined, 203
Kilogram, 199t
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Index  263
defined, 203
metric system, 206
Kilogramforce, 206
Kilopascal (kPa), 207
Knaus chronic health status score, 3
L
Laminar fluid flow through tube,
Poiseuille’s law and, 104–105
Laryngoscope blades, 130t
Law of Laplace (for a sphere), 108–109
Law of mass action, Henderson
Hasselbalch equation and, 73
Least common denominator (LCD), 172
Left atrium, hemodynamic parameters,
87t
Left cardiac work index
abbreviation, units, normal value for,
91
equation for, 91
Left ventricle, hemodynamic param
eters, 87t
Left ventricular stroke work index
abbreviation, units, normal value for,
90
equation for, 91
Length
base unit of SI, 199t
conversion factors for, 202t
conversion table for, 223t
Line, slope of, 179
Linear equations
general, 179
solving, 179–180
Linear functions, 178–179
Linear regression (method of least
squares), 192
Liquid conversion equivalents, metric,
apothecary, and household,
220t
Loaded breath, defined, 157
Logarithms, 182–185
antilogarithms, 184
antilogs of negative logarithms, 184
change of base, 185–186
characteristic of, 183
common, 182–183
defined, 182
mantissa, 184
natural, 185
Lowflow oxygen system, 116t
derivation of approximate Fio
2
for,
114–117
example, 115
Luminous intensity, base unit of SI, 199t
Lung compliance, 39
measuring, 39
prediction equations for, 39t
Lung injury score (Murray score), 21,
22t
Lungs
schematic representation, 133
symbol for, 213
Lung volume, step change in airway
pressure and change in, 153
M
Males, oxygen consumption as function
of age and heart rate for, 93t
Mandatory breaths, 159, 160
Mantissa, 184
MAP. See Mean arterial pressure
Mask with reservoir bag, in lowflow
oxygen system, 116t
Mass
base unit of SI, 199t
currently accepted nonSI units, 201t
Mass density, representative derived
units, 199t
Mathematical models
general equations, 164–165
for inspiration, 164
of pressurecontrolled mechanical
ventilation, 163–165
glossary, 163
model assumptions, 163–164
84096_INDX_Chatburn.indd 263 6/18/10 8:28:15 AM
264  Index
for single expiration, 164
Mathematical signs and symbols, 196t
Maximum expiratory pressure
defined, 39
prediction equations for, 40t
Maximum heart rate
defined, 45
prediction equations for, 45t
Maximum inspiratory pressure
defined, 39
prediction equations for, 39t
Maximum midexpiratory flow rate. See
Mean forced expiratory flow
during middle half of FVC
Maximum oxygen consumption
defined, 42
prediction equations for, 43t
Maximum oxygen pulse
defined, 45
prediction equation for, 45
Maximum safety pressure, defined, 147
Maximum voluntary ventilation, 38
defined, 38
prediction equations for, 38t
Maximum working pressure, defined,
147
McCabe classification, 2–3
Mean, 190
Mean airway pressure, defined, 147–
148, 163
Mean arterial pressure, 86–87
abbreviation, units, normal value for,
86
defined, 86
equations for, 86
Mechanical ventilation, 128–165
airways, 128–132
calculating partial pressure of
inspired oxygen, 52
classifying modes of, 156–162
assisted breath, 157
breath, 156–157
breath sequence, 159–160
control variable, 157
control variable, ventilatory pat
tern, and targeting scheme, 161
mandatory and spontaneous
breaths, 159
patient and machine triggering
and cycling, 158–159
targeting schemes, 160–161
trigger and cycle variables, 158
ventilatory pattern, 160
definition of terms for, 132–156
definitions for weaning and liberation
of, 25–26
mode, defined, 156
pressurecontrolled, mathematical
models of, 163–165
selection of modes named by
manufacturers classified using
taxonomy built from 10 apho
risms, 162t
ventilatorfree days, 22
Median, 190
Medical gas cylinder
color codes, 119t
dimensions, 120t
new standard threaded valve outlet
connections for, 121t
PPLT index, CGA standard, 121t,
122
specifications, 120t
Men, average rates of energy expendi
ture by, in U.S., 42t
Metabolic acidosis, expected compensa
tion for, 75t
Metabolic alkalosis, expected compen
sation for, 75t
Meter
base unit of SI, 199t
defined, 203
Methacholine challenge test, 41, 41t
Method of least squares, 192
Metropolitan Life Insurance (1983)
height and weight tables,
228–229t
Milliequivalent, 205
84096_INDX_Chatburn.indd 264 6/18/10 8:28:15 AM
Index  265
defined, 217
Millipascalmeter, 207
Minimum safety pressure, defined, 148
Minimum working pressure, defined,
148
Minute volume 1V
#
E2
defined, 148, 163
typical values for, 33t
Mode of mechanical ventilation,
defined, 156
MOD score. See Multiple Organ
Dysfunction score
Molal solution, defined, 217
Molar concentrations, 205
Molar solution, defined, 217
Mole
base unit of SI, 199t
defined, 204
Mole/valence, 205
MOP. See Maximum oxygen pulse
Motor, defined, 149
Mt. Everest, 53t
Multiple Organ Dysfunction score, 11t
defined, 11
severe sepsis and, 19
Multiplication
of fractions, 170
in scientific notation, 175
Multiplication property of fractions,
169–170
Multiplication rule, probability, 188–189
Murray score. See lung injury score
MVV. See Maximum voluntary ventila
tion
N
Nasal cannula or catheter, in lowflow
oxygen system, 116t
Natural logarithms, 185
Nebulizer performance, characterizing,
variables and calculated param
eters for, 233–234t
Negative angle, in trigonometry, 187
Negative logarithms, 184
Negative predictive rate, defined, 196
Neonates, acidbase map for, 77
Newborns
hypoxemia assessment in, 62t
Respiratory Distress Scoring system
for, 18, 18t
Silverman score for, 17, 18
Newton (N)
defined, 206
SI representative derived unit, 199t
n factorial, 189
Nipple, diameter index safety system,
122
NonSI units, currently accepted, 201t
Normal distribution curve
defined, 193
standard deviations in, 193
Normal solution, defined, 217
Null hypothesis, 194
Numerator, 169
O
Obstructive lung disease, exercise
response patterns with, 44t
Obstructive pulmonary disease
assessing severity of, 40t
pulmonary function profile, summary
in, 40t
Optimum control, targeting schemes,
161
Oral airways, dimensions of, 138t
Order of precedence, 168–169
Organ dysfunction
in critically ill patients, Multiple
Organ Dysfunction score and,
11, 11t
Sequential Organ Failure Assessment
score and, 6
Osmolar solution, defined, 217
Osmole solution, defined, 217
Oxygen, hemoglobin affinity for, 71–73
Oxygen administration, 113–117
blender or entrainment system equa
tions, 113–114
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266  Index
derivation of approximate Fio
2
for
lowflow oxygen system,
114–117
Oxygenation index
abbreviation, units, normal value for,
63
Oxygenation ratio, abbreviation, units,
normal value for, 62
Oxygen availability (delivery)
abbreviation, unit, normal value for,
92
defined, 92
equations for, 92
Oxygen consumption, 92–94
abbreviation, units, normal value for,
92
defined, 92
equations for, 93
as function of age and heart rate for
females, 94t
as function of age and heart rate for
males, 93t
prediction equations for
females, 93–94
males, 93
Oxygen content of blood, 65–66
abbreviations, units, normal value
for, 65
equations for, 66
Oxygen extraction index
abbreviation, units, normal value for,
95
equation for, 95
Oxygen extraction ratio
abbreviation, units, normal value for,
94
defined, 94
Oxygen flowmeter, obtaining desired
flow rate of given mixture
with, 118
Oxygen flow rates, 116, 117
Oxygen mask, in lowflow oxygen sys
tem, 116t
Oxygen requirements, for common
activities, 43t
Oxygen uptake
defined, 48
equations for, 48
P
Parabola, 181
Parameter, defined, 194
Partial pressure of inspired oxygen,
equation for, 51–52
Partial pressures
of gas in air at sea level, 53
of inhaled gases, Dalton’s law and,
104
normal, of respired gases, 54
Pascalmeter, 207
Pascal (Pa), 199t, 207
Patient initiated triggering and cycling,
mechanical ventilation and,
158–159
Patient system, defined, 149
PCCMV. See Pressurecontrolled con
tinuous mandatory ventilation
PCCSV. See Pressurecontrolled con
tinuous spontaneous ventilation
PCIMV. See Pressurecontrolled inter
mittent mandatory ventilation
Peak expiratory flow
defined, 37
prediction equations for, 37t
Peak inspiratory pressure
compliance and, 139, 141
defined, 149
Peak inspiratory pressure above set
PEEP, 163
Pearson r, 191–192
Pediatric body surface area chart,
227t
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Index  267
Pediatric Index of Mortality II, 15–16t
Pediatric patients, septic shock in, 19
Pediatric Risk of Mortality
defined, 14t
risk of death and predicted rate calcu
lation, 15
Pediatric Trauma Score, 5, 5t
PEEP. See Positive endexpiratory pres
sure
Pemax. See Maximum expiratory pres
sure
Pendelluft, defined, 149
Percentage concentrations of solutions,
219t
Percentage preparations, types of,
218–219
Percentile rank, 193
Permutations, 189
Pharmacological formulas and defini
tions, 217–219
Physical quantities in respiratory physi
ology, 204–208
amount of substance, 205
compliance, 208
force, 206
power, 207
pressure, 207
resistance, 208
solubility, 208
surface tension, 207
temperature, 208
volume, 204–205
volume flow rate, 205–206
work and energy, 207
Physiologic dead space (Bohr equation),
141
abbreviation, units, normal value for,
63
equation for, 63–64
graph relating minute ventilation and
Paco
2
for different values of, 64
prediction equation for, 64
reasons for ineffectiveness, 63
Pimax. See Maximum inspiratory pres
sure
PIM II. See Pediatric Index of Mortality
II
PIP. See Peak inspiratory pressure
Plane angle, currently accepted nonSI
units, 201t
Plateau pressure, defined, 149
Pleural space, 133
Pneumonia, clinical criteria for diag
nosis of, as defined by
National Nosocomial Infection
Surveillance System, 25t
Pneumonia definitions, 22–23
communityacquired pneumonia, 23
healthcareassociated pneumonia, 23
hospitalacquired pneumonia, 23
ventilatorassociated pneumonia, 23
Poiseuille’s law, equations for, 104–105
Polish words, commonly used, transla
tion of, 242–243t
Population, defined, 194
Positive angle, in trigonometry, 187
Positive endexpiratory pressure
patient circuit compliance and, 139
Positive phase of flow waveform,
breath, mode of mechanical
ventilation and, 156
Positive predictive rate, defined, 196
Postural drainage positions, 246–251
lingular segment, left upper lobe,
superior segment, inferior seg
ment, 248
lower lobes, anterior basal segments,
249
lower lobes, lateral basal segments,
249
lower lobes, posterior basal
segments, 250
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268  Index
lower lobes, superior segment, 248
right middle lobe, lateral segment;
medial segment, 247
upper lobes, anterior segment, 246
upper lobes, apical segment, 246
upper lobes, posterior segment, 247
Power, 194
of breathing, 163
in respiratory physiology, 207
ventilator, 149
PPLT. See Plateau pressure
Prefixes, for decimal multiples and sub
multiples, 199t
Pressure
conversion factors for, 202t
conversion table for, 224t
representative derived units, 199t
in respiratory physiology, 207
Pressurecontrolled continuous manda
tory ventilation, 160
Pressurecontrolled continuous sponta
neous ventilation, 160
Pressurecontrolled intermittent manda
tory ventilation, 160
Pressurecontrolled mechanical ventila
tion, mathematical models of,
163–165
Pressure control ventilation, proximal
airway pressure pattern and,
153
Pressure drop, defined, 150
Pressure hold, defined, 150
PRISM. See Pediatric Risk of Mortality
Probability, 188–190
addition rule, 188
combinations, 190
defined, 188
factorial notation (!), 189
multiplication rule, 188–189
permutations, 189
Product, 174
Prolonged weaning, mechanical ventila
tion, defined, 26
Proportional Assist, 157
Proportions, 173
PS MAX. See Maximum working pres
sure
PS Min. See Minimum safety pressure
Pulmonary artery
hemodynamic parameters, 87t
Pulmonary artery occlusion pressure,
hemodynamic parameters, 87t
Pulmonary embolism, Wells score for,
26, 28
Pulmonary function profile, summary,
in obstructive and restrictive
diseases, 40t
Pulmonary vascular resistance, abbrevia
tion, normal value and equa
tion for, 89
Pulmonary vascular resistance index
abbreviation, normal value for, 89
equation for, 89
P value, 194
PW Min, Minimum working pressure,
148
Q
Quadratic equations, 180–181
in standard form, 181
Quadratic formula, 181
Quaternary ammonium compounds,
capabilities of, in respiratory
care, 232t
R
Radians
defined, 186, 203
relationships between degrees and,
186
SI units, 199
Random numbers, 197–198t
generating, fraction for, 198
“Ratio by simple parts” prescription,
219
Ratios, 173
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Index  269
RDS. See Respiratory Distress Scoring
system
REE. See Resting energy expenditure
Relative humidity, equation for, 109
Representative derived units, 199t
Research hypothesis, defined, 194
Residual volume
defined, 35
prediction equations for, 35t
typical values for, 35t
Residual volume to total lung capacity
ratio, defined, 35
Resistance
airway, 150–151
calculating, 150
compliance times, time constant and,
153–155
conversion factors for, 203t
defined, 87, 150
Poiseuille’s law and, 105
pressure per unit flow, symbol for,
216
in respiratory physiology, 208
total respiratory, 151
Respiratory acidosis, expected compen
sation for, 75t
Respiratory alkalosis, expected compen
sation for, 75t
Respiratory Distress Scoring system, for
newborns, 18, 18t
Respiratory exchange ratio
defined, 51
equations for, 51
Respiratory physiology, physical quanti
ties in, 204–208
Respiratory quotient
defined, 50
for fat RQ, 50
glucose and, 50
for mixture of glucose, fat, and pro
tein, 51
Respiratory rate or frequency (f), 32
typical values for, 33t
Respiratory system
diagram of, with one compartment,
lungs and chest wall sub
divided into rib cage, dia
phragm, and abdominal wall
components, 134
schematic representation of, 133
Respiratory system mechanics
some measurable pressures used in,
137t
some pressure differences used for
describing, 137t
Resting energy expenditure
defined, 42
prediction equations for, 42t
Restrictive pulmonary diseases
assessment of severity for, 40t
pulmonary function profile, summary
in, 40t
Reynold’s number, 105–106
Right atrium, hemodynamic parameters,
87t
Right cardiac work index
abbreviation, unit, and normal value
for, 92
equation for, 92
Right ventricle, hemodynamic param
eters, 87t
Right ventricular stroke work index
abbreviation, units, normal value for,
91
equation for, 91
Roots, in scientific notation, 175
Rounding off, 177
RTS. See Revised trauma score
RV. See Residual volume
RV/TLC. See Residual volume to total
lung capacity ratio
S
Sample, defined, 194
SBE. See Standard base excess
Scientific notation, 174–175
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270  Index
addition and subtraction, 175
advantages with, 174
multiplication and division, 175
powers and roots, 175
Sea level
alveolar air equation nomogram at,
57
comparison of bloodgas values at
altitude and, 53t
partial pressures of gas in air at, 53
Secant, 187
Second
base unit of SI, 199t
defined, 203
Seed number, 198
Sensitivity, defined, 194
Sepsis
2001 expanded diagnostic criteria
for, 20–21
general variables, 20
hemodynamic variables, 20
inflammatory variables, 20
organ dysfunction variables,
20–21
tissue perfusion variables, 21
Sepsis definition, 18–19
clinical syndrome defined, 19
hypotension, 19
infection, 19
septic shock, 19
severe sepsis, 19
systemic inflammatory response syn
drome, 18–19
Septic shock, defined, 19
Sequential Organ Failure Assessment
score, 10t
defined, 6
severe sepsis and, 19
Servo control, targeting schemes, 161
Setpoint control, targeting schemes, 161
Severe sepsis, 19
SI, representative derived units, 199t
SID. See Strong ion difference
SiggaardAnderson nomogram, modi
fied, relating blood pH, bicar
bonate concentration, and
Pco
2
, 76
Sigh, ventilator, defined, 151
Significant figures, 176–177
calculations with, 177
rounding off, 177
zeros as, 176
Silverman score
evaluation, use, and interpretation of,
18
upper chest, lower chest, xiphoid
retraction, chin movement,
expiratory grunt, 17
Simple weaning, mechanical ventilation,
defined, 26
Simplified Acute Physiology Score,
expanded version and, 12–13t
Sine, 187
SI style specifications, 200–201t
SI units, 199–203
base units, 199t
Slope of the line, 179
Slow vital capacity, 33
Soaps, capabilities of, in respiratory
care, 232t
SOFA score. See Sequential Organ
Failure Assessment score
Solubility, in respiratory physiology,
208
Solute, defined, 217
Solutions
defined, 217
percentage concentrations of, 219t
Solvent, defined, 217
Spanish words, commonly used, transla
tion of, 237–239t
Specific compliance
defined, 152
symbol for, 211
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Index  271
Specificity, defined, 196
Sphere, law of Laplace for, 108–109
Spirometry, 33–41
Spirometry changes, significant, after
bronchial challenge, 41t
Spontaneous breaths, 159, 160
Square meter, 199t
Standard base excess, 80
Standard conditions, torr, pressure, and
dry, 205
Standard deviation, 191
Static compliance
defined, 140
Static respiratory system compliance,
140
Statistic, defined, 194
Statistical procedures, 190–196
common statistical terms, 194–196
correlation coefficient (Pearson r),
191–192
linear regression (method of least
squares), 192
mean, 190–191
median, 190
mode, 190
normal distribution curve, 193
pecentile rank, 193
standard deviation, 191
Steam, capabilities of, in respiratory
care, 232t
Steradian
defined, 204
SI units, 199
Stewart approach to acidbase disorders,
81–82
Stewart independent variables, classifi
cation of acidbase disorders
based on, 83
Stock solutions, calculating dosages
from, 218
STPD (standard temperature and pres
sure, dry), 123t
Stroke index, 85–86
abbreviation, units, normal value for,
85
equation for, 85–86
Stroke volume
abbreviation, units, normal value for,
85
equation for, 85
Stroke work, 90–92
left cardiac work index, 91
left ventricular stroke work index,
90–91
right cardiac work index, 92
right ventricular stroke work index,
91
Strong ion difference
abbreviation, units, normal value for,
82
equations for, 82
Strong ion gap
abbreviation, units, normal value and
equation for, 83
defined, 83
Subscripts, 211
Subtraction
of fractions with different denomina
tors, 172
of fractions with same denominator,
171
in scientific notation, 175
Suction settings vacuum settings, appro
priate, 132t
Surface tension
conversion factors for, 202t
in respiratory physiology, 207
Survival, TraumaInjury Severity Score
and probability of, 6
Survival probability, trauma score and,
4, 4t
SVC. See Slow vital capacity
Symbol conventions, summary of,
135t
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272  Index
Symbol modifier conventions, summary
of, 136t
Symbols
of American College of Chest
Physicians and American
Thoracic Society Joint
Committee, 211–215
base units of SI, 199t
currently accepted nonSI units, 201t
for decimal multiples and submul
tiples, 200t
mathematical, 196t
representative derived units, 199t
Systemic inflammatory response syn
drome, 18–19
Systemic vascular resistance, abbrevia
tion, normal value and equa
tion for, 88
Systemic vascular resistance index,
88–89
abbreviation, normal value for, 88
equation for, 88–89
T
Tablets, calculating dosages from, 218
Tangent, 187
Targeting schemes, mechanical ventila
tion, ranking, 160–161
TCT. See Total cycle time
TE. See Expiratory time
Temperature
conversion factors for, 203t
conversion table for, 222t
incubator, according to age, 231t
in respiratory physiology, 208
TGV. See Thoracic gas volume
Thermodynamic temperature, base unit
of SI, 199t
Thoracic gas volume, 38
Thorpe tube, 118
TI. See Inspiratory time
Tidal, symbol for, 214
Tidal volume, 32, 152, 163
typical values for, 33t
Time
base unit of SI, 199t
currently accepted nonSI units, 201t
symbol for, 214
Time constant, 153–155
Time constant curves, 155
Tissue perfusion variables, 2001
expanded criteria for sepsis
and, 21
Torr, defined, 155
Torricelli, Evangelista, 155
Total cycle time, 163
calculating, 146
defined, 155
Total lung capacity
defined, 35
prediction equations for, 35t
typical values for, 35t
Total respiratory resistance, 151
Trachea, dimensions from birth to adult,
231t
Tracheostomy tubes
approximate equivalents of, 128t
cuffless pediatric, dimensions of (in
millimeters), 129t
lowpressure cuffed, dimensions of
(in millimeters), 129t
Translations of commonly used words
French, 235–237t
German, 244–245t
Italian, 239–241t
Polish, 242–243t
Spanish, 237–239t
Transpulmonary pressure
calculating, 39
equation of motion and, 143
Transrespiratory pressure, 143
TraumaInjury Severity Score, 6
Trauma score, defined and points in,
4, 4t
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Index  273
Trigger, 156
Trigger variable, mechanical ventilation
and, 158
Trigonometric functions, 187
Trigonometry, 186–188
basic trigonometric identities, 188
functions in, 187
systems of angular measure, degree
and radius, 186
TRISS. See TraumaInjury Scoring
System; TraumaInjury
Severity Score
Truenegative rate, defined, 196
Truepositive rate, defined, 196
TTR. See Inspiratory triggering response
time
Tube radius, Poiseuille’s law and, 105
Tubes, conversion table for, 225t
Type I error, defined, 194
Type II error, defined, 194
U
Unassisted breath, defined, 157
Unit conversion, 173
Universe, defined, 194
V
VA. See Alveolar ventilation
Variable, defined, 194
Vascular resistance, 87–88
conversion factors for, 203t
defined, 87
equation for, 87–88
Vasopressor score, 21
VC. See Vital capacity
VCCMV. See Volumecontrolled con
tinuous mandatory ventilation
VCIMV. See Volumecontrolled inter
mittent mandatory ventilation
Vd. See Dead space volume
V
#
E. See Minute volume
Venous, symbol for, 215
Venoustoarterial shunt (classic form)
abbreviation, units, normal value for,
68
equation for, 68
Venoustoarterial shunt (clinical form)
abbreviation, units, normal value for,
68
equation for, 69
graph relating Pao
2
and inspired oxy
gen concentration for different
values of virtual shunt, 69
respiratory gas exchange and pres
sures, 70t
Ventilationperfusion ratio
abbreviation, units, normal value for,
67
equation for, 67
Ventilator
sigh, 151
work, 156
Ventilatorassociated pneumonia
Clinical Pulmonary Infection Score
and, 24
defined, 23
Ventilatorfree days, calculating, 22
Ventilator frequency
defined, 144
Ventilator power, 149
Ventilatory patterns, types of, 160
Vital capacity
abbreviation for, 216
defined, 33
prediction equations for, 34t
typical values for, 34t
Volume
conversion factors for, 202t
conversion table for, 223t
currently accepted nonSI units, 201t
representative derived units, 199t
in respiratory physiology, 204
Volumecontrolled continuous manda
tory ventilation, 160
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274  Index
Volumecontrolled intermittent manda
tory ventilation, 160
Volume flow rate, in respiratory physi
ology, 205–206
Volumelimited ventilation, tidal vol
ume and, 152
Volume to volume percentage prepara
tions, 218
Vo
2
max. See Maximum oxygen con
sumption
VT. See Tidal volume
VTR. See Inspiratory triggering volume
W
Water
approximate daily requirements for,
232t
Water dissociation equilibrium, equation
for, 81
Weak acid dissociation equilibrium,
equation for, 81–82
Weaning failure, mechanical ventilation,
defined, 26
Weaning success, mechanical ventila
tion, defined, 26
Weight, 206
conversion table for, 223t
Metropolitan Life Insurance (1983)
height and weight tables,
228–229t
Weight conversion equivalents, metric,
apothecary, and household,
220–221t
Weight to volume percentage prepara
tions, 218
Weight to weight percentage prepara
tions, 218
Wells score
for deep venous thrombosis,
28–29
for pulmonary embolism
modified score, 28
original score, 26, 28
Women, average rates of energy expen
diture by, in U.S., 42t
Work, ventilator, defined, 156
Work and energy
conversion factors for, 202t
representative derived units, 199t
in respiratory physiology, 207
Workenergy theorem, 207
Z
Zeros, as significant figures, 176
84096_INDX_Chatburn.indd 274 6/18/10 8:28:16 AM
Handbook of RespiRatoRy
Third Edition
CaRe
Robert L. Chatburn, MHHS, RRTNPS, FAARC Clinical Research Manager Respiratory Institute Cleveland Clinic Adjunct Associate Professor Department of Medicine Lerner College of Medicine of Case Western Reserve University Cleveland, Ohio Eduardo MirelesCabodevila, MD Director Medial Intensive Care Unit Assistant Professor Division of Pulmonary and Critical Care Medicine University of Arkansas for Medical Sciences Little Rock, Arkansas
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Jones & Bartlett Learning books and products are available through most bookstores and online booksellers. To contact Jones & Bartlett Learning directly, call 8008320034, fax 9784438000, or visit our website, www.jblearning.com. Substantial discounts on bulk quantities of Jones & Bartlett Learning publications are available to corporations, professional associations, and other qualified organizations. For details and specific discount information, contact the special sales department at Jones & Bartlett Learning via the above contact information or send an email to specialsales@jblearning.com. Copyright © 2011 by Jones & Bartlett Learning, LLC All rights reserved. No part of the material protected by this copyright may be reproduced or utilized in any form, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without written permission from the copyright owner. The authors, editor, and publisher have made every effort to provide accurate information. However, they are not responsible for errors, omissions, or for any outcomes related to the use of the contents of this book and take no responsibility for the use of the products and procedures described. Treatments and side effects described in this book may not be applicable to all people; likewise, some people may require a dose or experience a side effect that is not described herein. Drugs and medical devices are discussed that may have limited availability controlled by the Food and Drug Administration (FDA) for use only in a research study or clinical trial. Research, clinical practice, and government regulations often change the accepted standard in this field. When consideration is being given to use of any drug in the clinical setting, the health care provider or reader is responsible for determining FDA status of the drug, reading the package insert, and reviewing prescribing information for the most uptodate recommendations on dose, precautions, and contraindications, and determining the appropriate usage for the product. This is especially important in the case of drugs that are new or seldom used. Production Credits Publisher: David Cella Associate Editor: Maro Gartside Production Director: Amy Rose Senior Production Editor: Renée Sekerak Marketing Manager: Grace Richards Manufacturing and Inventory Control Supervisor: Amy Bacus Composition: Northeast Compositors Cover Design: Scott Moden Cover Image: © Bocos Benedict/ShutterStock, Inc. Printing and Binding: Malloy Incorporated Cover Printing: Malloy Incorporated
Library of Congress CataloginginPublication Data Chatburn, Robert L. Handbook of respiratory care / Robert L. Chatburn, Eduardo MirelesCabodevila.  3rd ed. p. ; cm. Includes bibliographical references and index. ISBN 9780763784096 (pbk. : alk. paper) 1. Respiratory therapyHandbooks, manuals, etc. I. MirelesCabodevila, Eduardo. II. Title. [DNLM: 1. Respiratory TherapyHandbooks. WF 39 C492h 2011] RC735.I5L68 2011 616.2’0046dc22 2010023519 6048 Printed in the United States of America 14 13 12 11 10 10 9 8 7 6 5 4 3 2 1
Dedication
I would like to dedicate this book to three people. First is my daughter Maya, who has taught me how strength of spirit can carry you through any adversity. Second is my daughter Kendra, who has taught me that our world needs better planners who are inspired by a vision for social justice. Third is my mentor at the Cleveland Clinic, Dr. James K. Stoller, who taught me that faith in people is better than the “carrot or the stick.” RLC To Marina, my wife, who endures, loves, guides, and nurtures. To my parents, Mario and Cristi, who taught me that it is not what they give you, it is what you do with it. To my sisters, for their persistence and joy. To my mentors, who had faith in me, and hopefully will never need to use the stick. EMC
Cathecholamine Index) 21 Acute Respiratory Distress Syndrome Definition 21 Lung Injury Score (Murray Score) 21 VentilatorFree Days 22 Pneumonia Definitions 22 Clinical Pulmonary Infection Score 24 Definitions for Weaning and Liberation of Mechanical Ventilation 25 Intubation Difficulty Scale 26 .CONTENTS Preface ix ChaPter 1 Scores and Definitions Used in Respiratory and Critical Care Research 1 Charlson Comorbidity Index 2 McCabe Classification 2 The Knaus Chronic Health Status Score 3 Glasgow Coma Scale 3 Trauma Score 4 Revised Trauma Score (RTS) 4 Pediatric Trauma Score 5 Injury Severity Score (ISS) 5 TraumaInjury Severity Score (TRISS) 6 Acute Physiology and Chronic Health Evaluation (APACHE II) 6 Sequential Organ Failure Assessment (SOFA) Score 6 Multiple Organ Dysfunction (MOD) Score 11 Simplified Acute Physiology Score (SAPS II) and Expanded Version 12 Pediatric Risk of Mortality (PRISM) 14 Pediatric Index of Mortality II (PIM II) 15 Apgar Score 16 Silverman Score 17 Newborn Respiratory Distress Scoring (RDS) System 18 Sepsis Definition 18 2001 Expanded Diagnostic Criteria for Sepsis 20 Vasopressor Score (Inotropic Score.
and Unit Conversion Exponents 174 Scientific Notation 174 Significant Figures 176 Functions 178 Quadratic Equations 180 Logarithms 182 Trigonometry 186 173 . Proportions. RPFT Spirometry 33 Bronchial Inhalation Challenges Exercise Physiology 42 41 ChaPter 3 Physiologic Monitoring 47 Gas Exchange 48 BloodGas Analysis: Traditional and the Stewart Method 73 Hemodynamics 84 ChaPter 4 Gas Therapy 97 The General Gas Law 98 Special Gas Laws 99 Oxygen Administration 113 Gas Cylinders 117 ChaPter 5 Mechanical Ventilation 127 Airways 128 Definition of Terms 132 Classifying Modes of Mechanical Ventilation 156 Mathematical Models of PressureControlled Mechanical Ventilation 163 ChaPter 6 Mathematical Procedures 167 Fundamental Axioms 168 Fractions 169 Ratios.vi  Contents Wells Score: Pulmonary Embolism 26 Wells Score: Deep Vein Thrombosis (DVT) 28 ChaPter 2 Pulmonary Function 31 Kevin McCarthy.
Contents  vii Probability 188 Statistical Procedures 190 Mathematical Signs and Symbols 195 The Greek Alphabet 196 Random Numbers 196 SI Units 198 Definitions of Basic Units 202 Physical Quantities in Respiratory Physiology 203 aPPenDix Reference Data 209 Clinical Abbreviations 210 Physiological Abbreviations 211 BloodGas Measurements 216 Basic Pharmacological Formulas and Definitions Miscellaneous Reference Data 220 Translation of Commonly Used Words 235 Postural Drainage Positions 246 217 Index 253 .
.
as a source tool when attempting to design research. figures. The new edition was extensively revised to reflect current clinical needs in practice and research. Yet much has not changed. It should also help as a starting point. and the standardization of nomenclatures and definitions. it must be understood that this compilation. All the chapters have new and easier to use tables. including advances in ventilation equipment. We have devoted the first chapter to the most commonly used scores and definitions in respiratory and critical care research. the universal presence of computers and the Internet in health care. During this period much has changed in the field of respiratory care. we now can obtain much information from the Internet. and 10 years since our last edition. This edition has been adapted to be a companion of the contemporary clinician in the Internet era. It is also intended for the clinician or researcher while reading an article. Nonetheless. however. formulating research. Our goal is for the reader to have the ability to easily find what each score or definition entails and how it is calculated. Indeed. The mechanical ventilation chapter now includes a simpletouse method to classify and understand all the modes of mechani . The Handbook of Respiratory Care is intended for both practicing clinicians and students wishing to have a summary of data not found in other textbooks. is subject to change according to geographical location and practice variation. a source to obtain basic data that serves as foundation to research and clinical practice. although intended to be global. and nomograms. or providing patient care. Chapter 2. gas therapy. Research and clinical practice still requires a reference standard. and mathematical procedures were revised and updated. The pulmonary function chapter. the Handbook represents years of collection of specific data that is not universally available. The chapters on physiology.PREFACE It has been 23 years since the First Edition of the Handbook of Respiratory Care. has been revised by Kevin McCarthy to reflect the recent changes in prediction equations in pulmonary function and exercise physiology. We added new concepts in physiology and acid–base physiology. the development of evidencebased medicine.
Respiratory Institute Cleveland. It is in this spirit that the Third Edition of the Handbook of Respiratory Care has been written. The Handbook of Respiratory Care compiles a wide variety of data from many sources in the fields of medicine. It is our hope that this edition becomes a good companion to the respiratory care clinicians and students attempting to navigate the overwhelming sea of information available. Ohio . mathematics. but in knowing where to find them when needed. RLC EMC ■■ Contributing Author Kevin McCarthy. Finally. and classifications. figures. It has been said that the key to knowledge is not in how many facts one may have memorized. and engineering. RPFT Technical Director/Manager Pulmonary Function Laboratories Cleveland Clinic. the appendix has grown in size and scope and now includes a collection of difficulttofind concepts. physics.x  Preface cal ventilation.
CHAPTER Scores and Definitions Used in Respiratory and Critical Care Research 1 .
G. and Lymphoma 3 points: Moderate or severe liver disease 6 points: Metastatic solid tumor. aplastic anemia. Congestive heart failure. Moderate or severe renal disease. Assigned weight for each patient’s condition. R. ■■ Charlson Comorbidity index Method for classifying comorbid conditions that might alter the risk of mortality for use in longitudinal studies. 1–2: 26%. 1 point: Myocardial infarct. and greater than or equal to 3: 59%. and AIDS Data from Charlson. M. gastrointestinal or obstetrical conditions) Category 2: Ultimately fatal disease (diseases estimated to become fatal within 4 years. We also include the latest consensus in some definitions used in respiratory and critical care. 3–4: 52%. cirrhosis. Mild liver disease. In parentheses we give the disease examples from the original article (McCabe. The total equals the score. 1: 25%. and Diabetes 2 points: Hemiplegia. G. 2: 48%. Cerebrovascular disease. Peripheral vascular disease. J Chronic Dis 40 (1987). 373–383. ■■ mCCabe ClassifiCation Classification generated to obtain comparisons regarding the importance of host factors based on the severity of the underlying disease.g. The predicted risk of death from comorbid disease at a 10year followup is 0: 8%. et al. and greater than or equal to 5: 85%. Leukemia. W. Arch of Int Med 110 (1962). Diabetes with endorgan damage. Chronic pulmonary disease. We present the scores as well as the original source. metastatic carcinomas. genitourinary. Connective tissue disease. chronic renal disease) . Category 1: Nonfatal disease (diabetes. Dementia. Any tumor.2  CHAPTER 1 Scores and Definitions Current articles use several scores and definitions to describe the population being studied. Evidently the prognosis for some has changed. Ulcer disease. E.. and Jackson. 847–891). e. The oneyear mortality rates for the different scores were 0: 12%.
Glasgow Coma Scale  3 Category 3: Rapidly fatal disease (acute leukemia, blastic relapse of chronic leukemia)
■■ the Knaus ChroniC health status sCore
Score used in the original APACHE article, and now used to describe baseline health status of the patients enrolled in studies. Class A: Normal health status Class B: Moderate activity limitation Class C: Severe activity limitation due to chronic disease Class D: Bedridden patient Data from Knaus et al. Crit Care Med 9(8) (1981), 591–597.
■■ GlasGow Coma sCale
(See Table 1–1.) Scale used to describe the neurological status of a patient, the neurological prognosis, and levels of brain injury. Points are added for each section.
Table 1–1 Glasgow Coma Scale
Eye opening Spontaneous To voice To pain None Oriented Confused Inappropriate words Incomprehensible words None Obeys commands Localizes Withdraws Flexion (decorticate) Extension (decerebrate) None Points 4 3 2 1 5 4 3 2 1 6 5 4 3 2 1
Verbal response
Motor response
Data from Teasdale, G. M. and Jennet, B. Lancet 304 (1974), 81–84.
4  CHAPTER 1 Scores and Definitions
■■ trauma sCore
(See Table 1–2.) A field scoring system in which values are correlated with probability of survival. Points are added from each category. A score of 1–5 points has a probability of survival of 0%; 6–7 points, 10%; 8–9 points, 22 to 37%; 10 points, 55%; 11 points, 71%; 12 points, 83%; and above 13 points, 90%.
Table 1–2 Trauma Score
Points Respiratory Rate Respiratory Effort Systolic Blood Pressure Capillary Refill Glasgow Coma Scale 4 10–24 3 25–35 2 .35 1 ,10 Normal 0 Apnea Shallow or retractions ,50 Not palpable Delayed None 5–7 3–4
.90 14–15
70–90 11–13
50–69 Normal 8–10
Data from Champion, H. R. et al. Crit Care Med 9 (1981), 672–676.
■■ revised trauma sCore (rts)
(See Table 1–3.) A revised form of the trauma score used by the TraumaInjury Scoring System (TRISS). It only uses three categories, for which a value is assigned. Each category value is multiplied by an assigned category weight, and the resultant values for each category are then added to obtain the RTS.
Table 1–3 Revised Trauma Score (RTS)
Points Respiratory Rate Systolic Blood Pressure Glasgow Coma Scale
*
4 10–29 .89 13–15
3 .29 76–89 9–12
2 6–9
1 1–5
0 0 0 3
Value
Weight* 0.2908 0.7326 0.9368
Final Value
50–75 1–49 6–8 4–5
Multiply Value by Weight to get Final Value. Add all final values to obtain RTS scores. Adapted from Champion, H. R. et al. J Trauma 29(5) (1989), 623–629.
Injury Severity Score (ISS)  5
■■ PediatriC trauma sCore
(See Table 1–4.) A score used to predict injury severity in pediatric patients. The sum of the points correlates with survival. Scores greater than 8 had a 0% mortality; between 0 and 8 had an increasing mortality. Scores below 0 had 100% mortality.
Table 1–4 Pediatric Trauma Score
Points Size Airway Systolic Blood Pressure or Pulse Mental Status Skeletal Cutaneous +2 .20 kg Normal .90 mmHg Pulse palpable wrist Awake None None +1 10–20 kg Maintainable 50–90 mmHg Pulse palpable groin Obtunded Closed fracture Minor 1 ,10 kg Unmaintainable ,50 mmHg No pulse palpable Coma/ Decerebrate Open/Multiple fractures Major/ Penetrating
Adapted from Tepas, J. J. et al. J. Trauma 38 (1988), 425–429.
■■ injury severity sCore (iss)
An anatomical scoring system that provides an overall score for patients with multiple injuries (Baker, et al. J Trauma 14 (1974), 187–196). Each injury is assigned an Abbreviated Injury Scale (AIS) score, allocated to one of six body regions (head, face, chest, abdomen, extremities, and external). Only the highest AIS score in each body region is used. The three most severely injured body regions have their score squared and added together to produce the ISS score. The AIS ranges from 0 to 6, 0 being no injury, and 6 unsurvivable injury. The ISS values range from 0 to 75. A patient with an ISS score of 6 in any category automatically obtains the maximum ISS score (75). The AIS scores used are revised and published by the Association for the Advancement of Automotive Medicine.
6  CHAPTER 1 Scores and Definitions
■■ traumainjury severity sCore (triss)
A score that uses values from the ISS, the RTS, the patient age, and the type of injury to quantify the probability of survival (Boyd, C. R. et al. J Trauma 27(4) (1987), 370–378). Age points: $55 years old = 1 point, otherwise 0 points. TRISS (blunt): b = 20.4499 + RTS 3 0.8085 + ISS 3 20.0835 + (age points) 3 21.7430 or TRISS (penetrating): b = 22.5355 + RTS 3 0.9934 + ISS 3 20.0651 + (age points) 3 21.1360 then Probability of survival = 1/(1 + eb) Probability of death = 1 – probability of survival.
■■ aCute PhysioloGy and ChroniC health evaluation (aPaChe ii)
(See Tables 1–5 and 1–6.) Used as a clinical scoring system to classify the severity of illness. APACHE II uses the worst last values in the last 24 hours. To calculate the predicted death rate: APACHE II SCORE = Acute Physiology Score + Age points + Chronic Health points Ln (R/1 2 R) = 23.517 + ( Apache II) * 0.146 + Diagnostic Category Weight + 0.603 if postemergency surgery. Predicted Death Rate = eLn (R/1 2 R)/(1 + eLn (R/1 2 R)) where “e” is the base of natural logarithm, 2.718.
■■ sequential orGan failure assessment (sofa) sCore
(See Table 1–7.) Score designed to describe the degree of organ dysfunction in critically ill patients.
Table 1–5 Acute Physiology and Chronic Health Evaluation (APACHE II)
APACHE II is used as a clinical scoring system to classify the severity of illness. It uses the worst last values in the last 24 hrs. Points Physiologic Variable 4 3 2 1 0 1 2 3 4
38.5–38.9 110–129 110–139 25–34 200–349 10–11 34–35.9 30–31.9 40–54 39.9–40.9 130–159 140–179 35–49 350–499 61–70 36–38.4 70–109 70–109 12–24 ,200 32–33.9 50–69 55–69 6–9 #29.9 #49 #39 #5
Temperature—rectal (8C) Mean Arterial Pressure—mmHg Heart Rate (ventricular response) Respiratory Rate (total) Oxygenation:
$41 $160 $180 $50 $500
155159 1.5–1.9
a. Fio2 $0.5 record AaDo2 b. Fio2 ,0.5 record only Pao2 Arterial pH Serum HCO3 use only if no ABG Serum Sodium (mMol/L) Serum Potassium (mMol/L) Serum Creatinine (mg/100 mL) double point score if acute renal failure 7.6–7.69 41–51.9 160–179 6–6.9 2–3.4 7.5–7.59 32–40.9 150–154 5.5–5.9 .70 7.33–7.49 22–31.9 130–149 3.5–5.4 0.6–1.4
55–60 7.15–7.24 15–17.9 111–119 3–3.4 7.25–7.32 18–21.9 120–129 2.5–2.9 ,0.6
$7.7 $52 $180 $7 $3.5
,55 ,7.15 ,15 #110 ,2.5
Acute Physiology and Chronic Health Evaluation (APACHE II)  7
(continued)
9 Score = 15 minus actual Glasgow coma scale Total Acute Physiology Score: Add points from the 12 parameters above 8  CHAPTER 1 Scores and Definitions Age Points Chronic Health Points: If patient has history of severe organ insufficiency or is #44 0 Immunocompromised assign points as follows: 45–54 2 5 points if nonoperative or emergency postoperative patients 55–64 3 2 points if elective postoperative patients 65–74 5 $75 6 Definitions: Organ insufficiency or immunocompromised state must have been evident prior to hospital admission.9 3–14. Liver failure: Cirrhosis and portal hypertension or manifestations of liver failure. or vascular pulmonary disease with severe exercise restriction or documented chronic hypoxia hypercapnia. Cardiovascular: New York Heart Association Class IV.1 Hematocrit (%) White Blood Cells Count total/ mm3 Glasgow Coma Score $60 50–59.9 1–2.9 Physiologic Variable 3 2 1 Points 0 1 2 3 4 .9 $40 20–39. secondary polycytemia.9 20–29. or ventilator dependency. . Respiratory: Chronic restrictive.9 46–49.20 . severe pulmonary hypertension.Table 1–5 Acute Physiology and Chronic Health Evaluation (APACHE II) (continued) 4 30–45.9 15–19. Renal: Chronic dialysis. obstructive. Immunocompromised: Patient receiving therapy or has disease that suppresses resistance to infection. R = risk of hospital death.
199 Craniotomy for ICH/SDH/SAH 20.108 Multiple trauma COPD 20.042 20.191 Metabolic/renal 20.501 abdominal aneurysm Postoperative If Postemergency Surgery Multiple trauma 21.699 20.128 Other Infection 0 Drug overdose 23.245 20.353 Neoplasm 0.315 20.376 20.259 Cardiovascular 0.228 20.367 Head injury Pulmonary edema (noncardiogenic) 20.759 Cardiogenic shock 20.352 Thoracic surgery for neoplasm 20.251 Neurologic 21.507 Cardiovascular Failure GI Bleeding 0.731 Gastrointestinal 0.684 21.168 Seizure disorder 20.470 Dissecting thoracic/ 0.712 21.658 Heart valve surgery Craniotomy for neoplasm 21.Acute Physiology and Chronic Health Evaluation (APACHE II)  9 Table 1–6 Diagnostic Categories Weight Leading to ICU Admission (APACHE II) Nonoperative Respiratory Failure Trauma Asthma/allergy 22.601 21.723 Pulmonary embolus 20.885 Coronary artery disease Sepsis 0.393 Neurologic 20.368 What System Was the Principal Congestive heart failure 20.334 21.642 Renal surgery for neoplasm 21.890 Post cardiac arrest 0.142 ICH/SDH/SAH 0.424 Reason for Admission? Hemorrhagic shock/hypovolemia 0.773 vascular disease Peripheral vascular surgery 21.955 20.891 Diabetic ketoacidosis 21.802 20.081 Admission due to chronic cardio21.261 20. Hypertension Rythm disturbance 21.113 Respiratory 20.439 Renal transplant Head trauma 20.517 Postrespiratory arrest 20.096 surgery Hemorrhagic shock 20.584 Aspiration/poisoning/toxic 20.682 20.204 20.493 20.788 20.079 (continued) .798 If Not in One of These Groups.185 Laminectomy and other spinal cord 20.
150 20.9 MAP .100 2.060 0.9 2.194 Cardiovascular Respiratory 20.9 or .20 .15 or epinephrine .140 0.407 Metabolic/renal Adapted from Knaus. What System Led to ICU Admission Postsurgery? Neurologic 21.10  CHAPTER 1 Scores and Definitions Table 1–6 Diagnostic Categories Weight Leading to ICU Admission (APACHE II cont.5 or .355 Respiratory insufficiency 20.2–1.9 Dopamine #5 or dobutamine (any dose) 3 .574 20.1 6–9 4 .4 3.50 6.0–11.0. Int Care Med 22 (1996). L.150 1. 707–710.196 0.300 .500 mL/ day . J.0–5. A.9 Dopamine . .007 Gastrointestinal 20. et al.400 .0–3.5–4. Table 1–7 Sequential Organ Failure Assessment (SOFA) Score Points Respiration Pao2/Fio2.463 GI perforation/obstruction 0. mmHg Coagulation Platelets 3 103/mm3 Liver Bilirubin.01 20.663 If Not in One of the Above.797 20.100 .610 20.014 GI surgery for neoplasm 20.) Postoperative If Postemergency Surgery GI bleeding 20.617 20.6 Central Nervous System Glasgow Coma Score Renal Creatinine mg/dl or Urine Output * 13–14 10–12 1.1 or norepinephrine .200 mL/day Vasopressors agents administered for at least 1 hr (mg/kg·min) Adapted from Vincent.248 0.1 .613 20.200 .70 2 .5 or epinephrine #0.2–1.0.1 or norepinephrine #0. 818–829. et al. W. mg/dl Cardiovascular Hypotension* 1 . Crit Care Med 13 (1985).12 Dopamine .
For patients receiving sedation or muscle relaxants normal brain function is assumed unless there is evidence of altered mentation.2–3.1) #20 (1.240 (14) . 1638–1652. Table 1–8 Multiple Organ Dysfunction Score Organ System Respiratory Pao2/Fio2 Renal Serum creatinine mmol/L (mg/dl) Liver Serum bilirubin mmol/L (mg/dl) Cardiovascular Pressureadjusted heart rate* Hematologic Platelet count mL 1023 Neurologic Glasgow coma score** * ** 0 .5) 10.120 15 81–120 13–14 51–80 10–21 21–50 7–9 #20 #6 Pressureadjusted heart rate = (heart rate 3 right atrial pressure)/mean arterial pressure. Crit Care Med 23 (1995).2) #10 1 226–300 101–200 (1. C.1–20 3 76–150 351–500 (4–5.6–7) 15.1–15 2 151–225 201–350 (2.500 (5.1–14) 20. Adapted from Marshall.) Score designed to describe the degree of organ dysfunction in critically ill patients. MOD Score 0 1–4 5–8 9–12 13–16 17–20 21–24 Intensive Care Unit Mortality 0% 12% 35% 25% 50% 75% 100% Hospital Mortality 0% 7% 16% 50% 70% 82% 100% Intensive Care Unit Stay (days) 2 3 6 10 17 21 n.1–30 4 #75 .3–4) 61–120 (3.3) 21–60 (1. J. et al.Multiple Organ Dysfunction (MOD) Score  11 ■■ multiPle orGan dysfunCtion (mod) sCore (See Table 1–8.7) .1–2.30 .7) 121–240 (7.300 #100 (1. It correlates with intensive care and hospital mortality and intensive care unit length of stay as originally described.a. .
9 4 points 28–83 6 points $ 20 3 points . beats/min Systolic Blood Pressure. 1. mEq/L 0 points .100 11 points $1 .9 Sodium. mEq/L Bilirubin. mg/dL White Blood Cell Count. °C Only if on Mechanical Ventilation* Pao2 mmHg/ Fio2 Urinary utput. 125 5 points .40 70–119 100–199 . Table 19 Simplified Acute Physiology Score (SAPS II) and Expanded Version SAPS II Age. mmHg Body Temperature. 3 or $5 3 points $145 1 point 15–19 3 points 4–5.9 3–4.9 4 points 11–13 5 points Abnormal value points 60–69 70–74 75–79 12 points 15 points 16 points 120–159 $ 160 . 05 11 points $ 84 10 points .12  CHAPTER 1 Scores and Definitions ■■ simPlified aCute PhysioloGy sCore (saPs ii) and exPanded version (See Table 1–9.4 14–15 . 40 4 points 7 points 11 points 70 –99 # 70 5 points 13 points $ 80 18 points 100–199 9 points .39 40–59 7 points 40–69 2 points . mg/dl Glasgow Coma Score 125–144 $20 . mEq/L Bicarbonate. The score revised in 2005 is referred to as the expanded version. years Heart rate. L/day O Blood Urea Nitrogen. The score uses the worst value (the one that gives the most points) in last 24 hours.0 12 points . mm3 Potassium.28 1–19.200 2 points $ 39 3 points $ 200 6 points 0.5–0.) Score to calculate to probability of hospital mortality.6 26 points (continued) . 15 6 points $6 9 points 9 – 10 7 points 6–8 13 points .
J.9 days 0. 2957–2963. JAMA 270 (1993).40 0 40–59 0.9323 Patient’s Location Before ICU Emergency room or mobile 0 emergency unit Ward in same hospital 0. R645–R652.1639 60–69 0.0844 3 SAPS II(expanded) + 6. and Le Gall. J. R.4761 + 0. R.0986 2 days 0. et al.6158 3 log[SAPS II(expanded) + 1] then predicted mortality = e(Logit)/[1 + e(Logit)] Adapted from Le Gall.0742 3 SAPS II score + the sum of the expanded variables Logit = 214.Simplified Acute Physiology Score (SAPS II) and Expanded Version  13 Table 19 Simplified Acute Physiology Score (SAPS II) and Expanded Version (cont.5284 .6645 Sex Male 0.6555 Other 0 Intoxication No 1. Critical Care (2005). SAPS II expanded Age.2606 Other hospital 0.79 0. years Value Points .3381 Clinical Category Medical patient 0.369 .) SAPS II Chronic Disease 0 points Abnormal value points SAPS II SCORE: add Metastatic cancer 9 points worst value for last Hematological malignancy 10 points 24 hours AIDS 17 points Medical 6 points Unscheduled surgical 8 points Type of Admission Scheduled surgical *Mechanical ventilation includes the use of continuous positive airway pressure (CPAP). et al. To calculate the predicted mortality: .1944 3–9 days 0.2739 70–79 0.24 hours 0 1 day 0.2083 Female 0 Length of Hospital Stay Before ICU Admission .6693 Yes 0 SAPS II (Expanded) = 0.
150 51–70 apnea or .50 .5 or 6.5–7.15 40–60 or 250–400 .5 . .160 . breaths per minute Pao2/Fio2 Paco2 torr Glasgow Coma Score Pupillary Reaction PT/PTT Total Bilirubin. 1110–1116.200 .5 3 control . mg/dL Bicarbonate. mEq/L Calcium.40 Children 65–75 or 150–200 50–64 or .5 7–8 or 12–15 .32 All ages Score 2 6 7 6 4 1 5 2 3 1 5 6 4 10 2 6 1 5 2 6 4 8 3 Systolic Blood Pressure.3. mg/dL Glucose.70 200–300 .3.7. mmHg Heart Rate.80 or .90 or .) Score designed to calculate the mortality risk in the pediatric intensive care unit.0 or .400 .200 51–65 .5 (. et al.110 .8 unequal or dilated fixed and dilated 1. Crit Care Med 16 (1988).7 or . M.40 or . mEq/L Adapted from Pollack. mmHg Diastolic Blood Pressure. mg/dl Potassium. M.90 .65 . beats per minute Respiratory Rate.160 61–90 apnea or .1 month old) 3–3.1 year old) 55–65 or 130–160 40–54 or . Developed from the original Physiologic Stability Table 1–10 Pediatric Risk of Mortality (PRISM) Infants (.16 or .14  CHAPTER 1 Scores and Definitions ■■ PediatriC risK of mortality (Prism) (See Table 1–10.
005 3 (age in months)] 2 0. r = (0.782 Then predicted death rate = er/(1 + er ) ■■ PediatriC index of mortality ii (Pim ii) (See Table 1–11. First. yes = 1 no = 0. Values are measured during the first 24 hours after intensive care admission. yes = 1 (continued) b Pupillary reactions to bright light c d e f g h (Fio2 3 100)/Pao2.207 3 PRISM) 2 [0. mmHg Value MV if unknown = 120 cardiac arrest = 0 shock with unmeasurable SBP = 30 . Table 1–11 Pediatric Index of Mortality II (PIM II) Variable a Systolic blood pressure.3 mm and both fixed = 1 other or unknown =0 MV if unknown = 0 MV if unknown = 0 no = 0.) Score used to estimate mortality risk from data obtained for each variable measured within the period from the time of first contact (anywhere by an ICU doctor) to 1 hour after arrival to the intensive care unit. calculate the risk of death (r). mmol/L Mechanical ventilation at any time during the first hour in ICU Elective admission to ICU Recovery from surgery or a procedure is the main reason for ICU admission Admitted following cardiac bypass . mmHg Base excess in arterial or capillary blood. yes = 1 no = 0.433 3 1 (if postoperative ) 2 4. yes = 1 no = 0.Pediatric Index of Mortality II (PIM II)  15 Index.
It may be repeated at 5minute intervals for infants with 5minute scores .0791 3 b) + (0.01395 3 [absolute (a 2 120)]} + (3.16  CHAPTER 1 Scores and Definitions Table 1–11 Pediatric Index of Mortality II (PIM II) (continued) Variable i Value Highrisk diagnosis is the main reason for ICU no = 0.0244 3 g) + (0. . Enter the value for each variable in the equation.) Score that is assessed at 1 and 5 minutes after delivery. Int Care Med 29 (2003). yes = 1 admission Cardiac arrest preceding ICU admission Severe combined immune deficiency Leukemia or lymphoma after first induction Spontaneous cerebral hemorrhage Cardiomyopathy or myocarditis Hypoplastic left heart syndrome HIV infection Liver failure is the main reason for ICU admission Neurodegenerative disorder Lowrisk diagnosis is the main reason for ICU no = 0.9282 3 f) 2 (1.3352 3 e) – (0.104 3 absolute d) + (1. yes = 1 admission Asthma Bronchiolitis Croup Obstructive sleep apnea Diabetic ketoacidosis j MV = Measured value.7507 3 h) + (1. 278–285.7. Add points for each category.6829 3 i) 2 (1. Adapted from Slater et al.8841 Then probability of death = ePIM2/(1 + ePIM2) ■■ aPGar sCore (See Table 1–12.5770 3 j) 2 4.2888 3 c) + (0. PIM2 = {0.
1–10.100 bpm Good. Interpretation: 10: Best possible condition. Pediatrics 17 (1956). shallow Some flexion of extremities Grimace Body pink.4: Infant requires immediate intervention such as intubation and further examination.100 bpm Irregular. A. 4–6: Infant requires close observation and intervention such as suctioning. crying Active motion Cry Completely pink Data from Apgar. Anesth Analg 32 (1953). . V. . pale 1 . and Andersen. 260.Silverman Score  17 Table 1–12 Apgar Score Sign Heart Rate Respiratory Effort Muscle Tone Reflex Irritability Color 0 Absent Absent Limp No response Blue.).) Upper Chest Grade 0 Lower Chest Xiphoid Retraction Chin Movement Expiratory Grunt Synchronized No Retraction None No Movement of Chin None Grade 1 Lag on Insp. Just Visible Just Visible Chin Descends Lips Closed Stethos. D. W. extremities blue 2 . no treatment. ■■ silverman sCore (See Figure 1–1. 7–9: Adequate. H. Only UH HH Grade 2 SeeSaw Marked Marked Lips Part Naked Ear Figure 11 Silverman score. (Adapted from Silverman.
Adapted from Downes. 10 indicates severe respiratory distress. M. 325–331. et al. Body temperature greater than 388C 2. Interpretation: Zero indicates no respiratory distress. Table 1–13 Newborn Respiratory Distress Scoring (RDS) System* RDS Score Cyanosis Retractions Grunting Air Entry (crying)* Respiratory Rate (min) * 0 None None None Clear 60 1 Inroom air Mild Audible with stethoscope Delayed or decreased 60–80 2 In 40% Fio2 Severe Audible without stethoscope Barely audible .) Systemic Inflammatory Response Syndrome More than one of the following: 1. and grunting. R. ■■ newborn resPiratory distress sCorinG (rds) system (See Table 1–13. Clinical RDS = score $4 (overall mortality 25%). nasal flaring. (From Bone. Use: Evaluates respiratory distress in newborns. Critical Car Med 31 (2003). J.18  CHAPTER 1 Scores and Definitions Evaluates: Retractions.) The sum of all the individual scores. 1250–1256. M. Although it has limitations. score $8 = severe respiratory distress with impending failure (65% mortality). CHEST 101 (1992). C. 7 or greater indicates impending respiratory failure. 1644–1655 and Levy. Heart rate greater than 90 beats per minute . et al. a classification has been widely adopted.80 or apneic episodes Air entry represents the quality of the inspiratory breath sounds as heard in the midaxillary line. Clin Pediatr (Phila) 9(6) (1970). when revised 10 years later the same definitions stand with some new expansions. ■■ sePsis definition In an effort to standardize patients into categories of sepsis. J. et al.
2 SD below normal for their age).or hypothermia (rectal temperature . or a reduction in systolic blood pressure of . Sepsis Clinical syndrome defined by the presence of both infection (suspected or confirmed) and systemic inflammatory response. Infection Pathologic process caused by the invasion of normally sterile tissue or fluid or body cavity by pathogenic or potentially pathogenic microorganism.40 mmHg from baseline despite adequate volume resuscitation. increased serum lactate level.358C). capillary refill .2 s. Septic shock in pediatric patients is defined as tachycardia with signs of decreased organ perfusion (decreased peripheral pulses compared with central pulses. hypoxemia. a mean arterial pressure . tachycardia and one of the following indications of organ dysfunction: altered mental status.Sepsis Definition  19 3.60 mmHg. May use the SOFA score or the MOD score (see above) to define organ dysfunction. Severe Sepsis Sepsis complicated by organ dysfunction. mottled or cool extremities. or bounding pulses. White blood cell count $12000 or #4000/cu mm. altered mental status. . Hypotension Systolic blood pressure below 90 mmHg (in children . Tachypnea (respiratory rate .5 or . Septic Shock Acute circulatory failure characterized by persistent arterial hypotension unexplained by other causes.32 mmHg at sea level) 4. or decreased urine output). Diagnostic criteria for sepsis in the pediatric population are signs and symptoms of inflammation plus infection with hyper.20 breaths per minute) or hyperventilation (Paco2 .38.
0.368C) Heart rate .5 mL/kg/h or 45 mmol/L for at least 2 h) Creatinine increase .38C) Hypothermia (core temperature .5 Lmin ? m2 Organ Dysfunction Variables Arterial hypoxemia (Pao2/Fio2 .2 SD above the normal value Hemodynamic Variables Arterial hypotension (systolic blood pressure .5 or aPTT . mean arterial pressure .2 SD below normal for age) Mixed venous oxygen saturation .20  CHAPTER 1 Scores and Definitions ■■ 2001 exPanded diaGnostiC Criteria for sePsis Infection (defined as a pathologic process induced by a microorganism).1.70% Cardiac index .000 mL) Leukopenia (white blood cell count .60 s) Ileus (absent bowel sounds) .3.70.12.4000 mL) Normal white blood cell count with .20 mL/kg over 24 h) Hyperglycemia (plasma glucose .0.10% immature forms Plasma Creactive protein .90 mm Hg.90 min or .5 mg/dL Coagulation abnormalities (INR .40 mm Hg in adults or .300) Acute oliguria (urine output .2 SD above the normal value Plasma procalcitonin .2 SD above the normal value for age Tachypnea Altered mental status Significant edema or positive fluid balance (.120 mg/dL) in the absence of diabetes Inflammatory Variables Leukocytosis (white blood cell count .38. or a systolic blood pressure decrease . documented or suspected. and some of the following: General Variables Fever (core temperature .
■■ aCute resPiratory distress syndrome definition As defined by Bernard. the lung injury score was part of a threecomponent definition in the original paper.) Designed to characterize the presence and extent of a pulmonary damage.100.1 mmol/L) Decreased capillary refill or mottling ■■ vasoPressor sCore (inotroPiC sCore.Lung Injury Score (Murray Score)  21 Thrombocytopenia (platelet count . but it is still used rather to characterize the severity of lung disease in clinical trials. et al. 2445–2452. ALI) ■■ Bilateral infiltrates on chest radiograph consistent with pulmonary edema ■■ Pulmonary artery occlusion pressure #18 mmHg or no clinical evidence of left atrial hypertension ■■ lunG injury sCore (murray sCore) (See Table 1–14. (Am J Respir Crit Care Med 149 (1994). .000 mL) Hyperbilirubinemia (plasma total bilirubin . The lung injury score was used as the definition for ARDS (Score . CatheCholamine index) Score used to describe the dose of vasopressors used.4 mg/dL) Tissue Perfusion Variables Hyperlactatemia (. et al. D. N. 818– 824).2. inotropic score = (dopamine dose 3 1) + (dobutamine dose 3 1) + (adrenaline dose 3 100) + (noradrenaline dose 3 100) + (phenylephrine dose 3 100) vasopressor dependency index = inotropic score/MAP Data from Cruz. JAMA 301(23) (2009).5). all of the following criteria must be present ■■ Acute onset ■■ Pao2/Fio2 #200 mmHg (ARDS) ■■ Pao2/Fio2 #300 mmHg (acute lung injury.
Am Rev Respir Dis 138 (1988). et al. Crit Care Med 30 (2002). Adapted from Murray. 388–416).100 $15 #19 Add individual scores for each category and then divide by the number of components used. The number is calculated as ventilatorfree days = number of days from day 1 to day 28 on which a patient breathed without assistance (if the period of unassisted breathing lasted at least 48 consecutive hours). D. et al. ■■ ventilatorfree days The number of ventilatorfree days is used to evaluate the effects of therapies in critical care. 720–723.e. It assumes that any therapy that decreases duration of mechanical ventilation in patients who survive also increases the number of patients that survive. . This number combines the effects of mortality and the duration of mechanical ventilation in patients who survive.. (i.22  CHAPTER 1 Scores and Definitions Table 1–14 Lung Injury Score (Murray Score) SCORE 0 None 1 1 2 2 3 3 4 4 Chest Radiograph Number of Quadrants with Alveolar Consolidation Hypoxemia Pao2/Fio2 PEEP cmH20 Lung Compliance mL/cm H20 $300 #5 $80 225–299 6–8 60–79 175–224 9–11 40–59 100–174 12–14 20–39 .) ■■ Pneumonia definitions The following definitions are from the American Thoracic Society and Infectious Diseases Society of America in 2005 (Am J Respir Crit Care Med 171 (2005). 1772– 1777. If patient dies or requires more than 28 days of mechanical ventilation. (From Schoenfeld. not all patients have all measurements). A. the value is 0.
or wound care in last 30 days. ■■ High frequency of antibiotic resistance in community or specific hospital unit.Pneumonia Definitions  23 CommunityAcquired Pneumonia Pneumonia occurring within 48 hours of admission in patients with no criteria for healthcareassociated pneumonia. ■■ Presence of healthcareassociated pneumonia risk factors for multidrug resistant bacteria. Hemodialysis at a hospital or clinic. Antibiotic therapy. 388C. leukocytosis or leukopenia. Home infusion therapy or wound care. Family member with infection due to a multidrug resistant bacteria. ■■ Immunosuppressive disease or therapy. and purulent secretions. Defined as a new lung infiltrate on chest radiography plus at least two of the following: fever. Nursing home or longterm acutecare facility resident. VentilatorAssociated Pneumonia ■■ ■■ Pneumonia occurring . . chemotherapy. HospitalAcquired Pneumonia Pneumonia occurring $48 hours after hospital admission Risk factors for multidrug resistant bacteria: ■■ Antibiotic therapy within 90 days of infection. ■■ Current hospitalization of $5 days.48 hours after endotracheal intubation. HealthcareAssociated Pneumonia Pneumonia occurring #48 hours of admission in patients with any risk factor for multidrug resistant bacteria as cause of infection: ■■ ■■ ■■ ■■ ■■ ■■ Hospitalization for $2 days in an acutecare facility within 90 days of infection.
1121–1129) and later modified by Singh et al. showed that some patients with a low clinical suspicion of ventilatorassociated pneumonia (CPIS #6) can have antibiotics safely discontinued after 3 days. 505–511.9 . AJRCCM 162 (2000).4 $4 and #11 None . 505–511).) Originally described by Pugin et al. (Am Rev Resp Dis 143 (1991). Singh et al.18 mmHg and acute bilateral infiltrates. * ARDS (Acute Respiratory Distress Syndrome) defined as Pao2/Fio2 200. if the subsequent course suggests that the probability of pneumonia is still low.5 and #38.4 Purulent #240 and no ARDS Localized opacity progression (after HF** and ARDS excluded) Pathogenic bacteria cultured in rare/few quantities or no growth Pathogenic bacteria cultured in moderate or heavy quantity Add a point (+1) if: Bands are . ** HF: heart failure.5 and #38. PAOP . Adapted from Singh et al.12 Nonpurulent 2 $39 or #36. (See also Table 1–16.) Table 1–15 Clinical Pulmonary Infection Score Score Temperature Blood Leukocytes 103 mm3 Tracheal S ecretions Oxygenation Pao2/Fio2. mmHg Chest Radiography Progression of Radiographic Opacities Culture of Tracheal Aspirate 0 $36.240 or ARDS* No opacity No progression Diffuse (patchy) opacities 1 $38. A score developed to establish a numerical value of clinical.4 or . . and laboratory markers for pneumonia. Scores above 6 suggest pneumonia (specificity and sensitivity have been consistently less than in initial validation study). radiographic. (AJRCCM 162 (2000).24  CHAPTER 1 Scores and Definitions ■■ CliniCal Pulmonary infeCtion sCore (See Table 1–15.50% or same pathogenic bacteria seen on Gram stain.
or tachypnea Rales or bronchial breath sounds Worsening gas exchange.000/mL or . pleural fluid. or increase in respiratory secretions or suctioning requirements Newonset or worsening cough.70 yr old. NNIS Criteria for Determining Nosocomial Pneumonia.4. increased ventilatory support Microbiology (optional) Positive culture result (one): blood (unrelated to other source).388C (100. CDC. Table 1–18 shows the latest multisociety attempt to define weaning/liberation of mechanical ventilation. quantitative culture by BAL or PSB.48F) with no other recognized cause WBC count .000 mL For adults .S. We favor the term liberation or discontinuation to describe the cessation of ventilator support. Department of Health and Human Services. Atlanta. GA: U.5% BALobtained cells contain intracellular bacteria BAL: Bronchoalveolar lavage. altered mental status with no other recognized cause And at least two of the following: Newonset purulent sputum or change in character of sputum. CHEST. dyspnea. . 2003.Definitions for Weaning and Liberation of Mechanical Ventilation  25 Table 1–16 Clinical Criteria for the Diagnosis of Pneumonia as Defined by the National Nosocomial Infection Surveillance System Radiographic Two or more serial chest radiographs with new or progressive and persistent infiltrate or cavitation or consolidation (one radiograph is sufficient in patients without underlying cardiopulmonary disease) Clinical One of the following: Fever . 2006.12. The process of freeing a patient from ventilator assistance is often termed weaning (which for some includes the process of extubation). increased oxygen requirements. ■■ definitions for weaninG and liberation of meChaniCal ventilation Multiple terms and definitions are used indistinctly to describe the process of discontinuation of mechanical ventilation. . Prozencaski. PSB: Protected specimen brush From CDC. 130:597–604.
07 pH units. Both are presented here.7. No alternative diagnosis better explains the illness (3 points).) Quantitative score used to evaluate intubation difficulty. heart rate . pain with palpation (3 points).90%. depressed mental status. .8 mmHg.180 mmHg or increased by $20% or .50 mmHg or an increase in Paco2 .32 or a decrease in pH $0.26  CHAPTER 1 Scores and Definitions Table 1–17 Definitions for Weaning and Liberation of Mechanical Ventilation Weaning success: is the extubation and the absence of ventilatory support for the following 48 h Weaning failure: is one of the following: (1) failed spontaneous breathing trial. shallow breathing index (respiratory rate/tidal volume) . or (2) reintubation and/or resumption of ventilator support following successful extubation.5 or Sao2 . increased accessory muscle activity. ■■ intubation diffiCulty sCale (See Table 1–18. Eur Respir J 29 (2007). anxiety. respiratory rate . conditions.35 breaths/min or increased by . and techniques. J.140 beats/ min or increased by $20%.105 breaths/min/L. M. Paco2 . diaphoresis. Original Score ■■ ■■ Symptoms of deep venous thrombosis (DVT): Leg swelling.90 mmHg. or as long as 7 days from the first attempt to achieve successful weaning Prolonged weaning: Patients who fail at least three weaning attempts or require more than 7 days of weaning after the first spontaneous breathing trial Failed spontaneous breathing trial: Subjective criteria: Agitation. ■■ wells sCore: Pulmonary embolism The original interpretation of results of the Wells score for pulmonary embolism was modified for the Christopher study.50%. 1033–1056. systolic blood pressure . or cardiac arrhythmias Data from Boles. or (3) death within 48 h following extubation Simple weaning: Patients who proceed from initiation of weaning to successful extubation on the first attempt Difficult weaning: Patients who fail initial weaning and require up to three spontaneous breathing trials. et al. cyanosis. pH . facial signs of distress and dyspnea Objective criteria: Pao2 #50–60 mmHg on Fio2 $0.
. Wells Score: Pulmonary Embolism  27 Adapted from Adnet. Add all points to obtain total score. 1290–1297. technique) Complete visualizaInferior portion of Only the epiglottis tion of the vocal the glottis cords Little effort Increased effort Applied Not applied** Abduction Adduction *Use Cormack’s visual grade (Anesthesiology 39 (1984). position.Table 1–18 Intubation Difficulty Scale 3 Number of Attempts Number of Operators Number of Alternative Techniques Glotic Exposure* Nonvisualized epiglottis Lifting Force Required Laryngeal Pressure Vocal Cord Mobility Score 0 1 2 +1 for each attempt +1 for each operator +1 for each change (blade. equipment. 1105–1111). ** Sellick maneuver is used to prevent aspiration gastric contents and gives no points. use total value previous to abandoning effort. If unable to intubate. Anesthesiology 87(6) (1997). et al. aproach.
Recently bedridden ($3 days) or major surgery within past 4 weeks (1 point).5 points). Immobilization ($3 days) or surgery in the previous four weeks (1. Both are presented here. ■■ wells sCore: deeP venous thrombosis (dvt) The original Wells score and its interpretation were modified in a later article. Localized tenderness in deep vein system (1 point). Calf swelling 3 cm greater than other leg (measured 10 cm below the tibial tuberosity) (1 point). Results: More than 4 points: Pulmonary embolism likely Less than 4 points: Pulmonary embolism unlikely Data from Wells. JAMA 295 (2006). Prior history of DVT or pulmonary embolism (1. Original Score ■■ ■■ ■■ ■■ ■■ ■■ ■■ Paralysis. et al. paresis. A. and van Belle. .100 (1. Thrombosis and Haemostasis 83 (2000). Swelling of entire leg (1 point).5 points). Collateral nonvaricose superficial veins (1 point). Pitting edema greater in the symptomatic leg (1 point). Results: 7–12 points: High probability 2–6 points: Moderate probability 0–1 points: Low Probability Modified Score Use original criteria. Presence of hemoptysis (1 point). Presence of malignancy (1 point). or recent orthopedic casting of lower extremity (1 point). et al.28  CHAPTER 1 Scores and Definitions ■■ ■■ ■■ ■■ ■■ Tachycardia with pulse .5 points). 416– 420. 172. S. P.
N Engl J Med 349 (2003). points: DVT likely 1 or less points: DVT unlikely Data from Wells. Anderson. 1795–1798. 179–1227. Results: 2 or . et al. and Wells. ■■ Previous documented DVT (1 point). Lancet 350 (1997). Rodger. P.. Alternative diagnosis more likely than DVT (22 points). R. M. S. P.Wells Score: Deep Venous Thrombosis (DVT)  29 ■■ ■■ Active cancer or cancer treated within 6 months (1 point).. S. .. et al. Results: 3–8 points: High probability of DVT 1–2 points: Moderate probability 22–0 points : Low Probability Modified Score Add this criteria to the original. D.
.
RPFT 2 .CHAPTER Pulmonary Function Kevin McCarthy.
.6 mL/kg Respiratory Rate or Frequency (f) The number of respiratory cycles per unit of time. usually 1 minute.32  CHAPTER 2 Pulmonary Function The following prediction equations are compiled from the works of many scientific investigators. . The NHANES III (Hankinson et al.16 age (years) Alveolar Ventilation (Va) The effective rate at which air enters the region of the lungs that participates in gas exchange. Typical normal values for spirometry volumes in nonCaucasian individuals range from 85%–88% of the Caucasian predicted value. Table 2–2 Respiratory Rate or Frequency (f) Age (6–25 yr) f (bpm) = 30. Typical values for the preceding and more are shown in Table 2–3.1 mL/kg Child Vt = 7. Prediction equations are shown in Table 2–1. Recent work has shown that Caucasians have significantly higher values for lung function than nearly every other ethnic group studied. Caucasian values are presented here. and MexicanAmericans. AfricanAmericans.07 + 0.9 2 0.) predicted set for spirometry provides specific regression equations for Caucasians. Table 2–1 Tidal Volume (Vt) Infant Vt = 7.8 mL/kg Female adult Vt = 6. Prediction equations for respiratory frequency are shown in Table 2–2.5 mL/kg Male adult Vt = 7. The calculation of alveolar ventilation is # Va = f 3 (Vt 2 Vd) where Vd = physiologic dead space volume. Readers are directed to the reference to see these specific reference equations.80 age (years) Age (25–80 yr) f (bpm) = 7. Tidal Volume (Vt) The volume of gas inspired or expired during one respiration cycle.
the total volume exhaled is called the forced vital capacity (FVC). # Dead Space (Vd). . this is called the slow vital capacity (SVC). Frequency (f). the difference between any of these volumes is minimal. then inhales maximally. Typical values are shown in Table 2–5. and the prediction equations for FVC can be used for SVC or IVC. respectively. The latter two methods are generally used for lung volume determinations and diffusing capacity tests. Prediction equations are shown in Table 2–4. generally considered to be 15 s. When the patient exhales with less than maximal force for as long as can be safely tolerated. sustained until flow falls below 25 mL/s for at least one second or for as long as the patient can safely continue up to a timed endpoint. In individuals with normal lung function. Vital Capacity (VC) Volume change of the lungs measured on a complete expiration after a maximum inspiration or a complete inspiration after a maximum expiration. this is called the inspiratory vital capacity (IVC).5 450 21 1368 49 1620 105 2480 141 3066 150 4200 ■■ Spirometry Spirometry typically consists of a maximum inspiration to complete maximal voluntary lung expansion followed by maximal forced expiration. and Alveolar Ventilation (Va) Age (yr) Newborn 1 5 12 15 Adult 20 78 130 260 360 500 Vt (mL) f (bpm) 36 24 20 16 14 12 # 720 1872 2600 4160 5040 6000 Ve (mL/min) Vd (mL) # Va (mL/min) 7. Minute Volume (Ve).Spirometry  33 # Table 2–3 Typical Values for Tidal Volume (Vt). In this setting. When the patient exhales as completely or for as long as possible.
25 2.0031 age 2 3.00018624 height (cm)2 Female child (8–17 yr).50 Crying vital capacity (CVC).1 height (cm) 2 20. Prediction equations are shown in Table 2–6.90 2.036 height (cm) + 0. 8 yr.30 Adult male.87 3 1023 Male child (8–19 yr).75 VC 100* * 15 (L) 4.4 height (cm) 2 22.0157 length (cm)2.009 age 2 5.182 Table 2–7 Typical Values for Functional Residual Capacity Age (yr) 5 12 15 Adult (M) FRC (L) 0.63 height (cm)2.0 age 2 2810 Female adult ($18 yr).75 .00 Adult female.010133 age2 + 0.29 Female adult FRC (L) = 0.472 height (cm) + 0.36 length (cm) 2 104 Child .0 age 2 2350 Table 2–5 Typical Values for Vital Capacity Age (yr) Newborn 1 5 12 (mL) (mL) (L) (L) 500 1.20415 age + 0.00088 height (cm)2. (L) 20. (L) 48.34  CHAPTER 2 Pulmonary Function Table 2–4 Prediction Equations for Vital Capacity Infant (crying VC). (L) 3. (L) 40.7 1.238 Child (5–16 yr) FRC (L) = [0. (L) 20.80 3.91] 3 1023 Male adult FRC (L) = 0.00 Adult (F) 2. (mL) 1.2584 2 0.00011496 height (cm)2 Male adult ($20 yr). Functional Residual Capacity (FRC) The volume of gas remaining in the lungs at the end of relaxed (passive) expiration. (L) 5. (mL) 3.8710 + 0.06537 age + 0. Table 2–6 Prediction Equations for Functional Residual Capacity Infant (1–5 days) FRC (mL) = 30 mL/kg Small child (1 mo–5 yr) FRC (mL) = 0. Typical values are shown in Table 2–7.
0032 age 27.0207 age 2 2.04] 3 1023 Male adult RV (L) = 0. RV/TLC = 25% ± 5% in healthy individuals .90 1. Prediction equations are shown in Table 2–10.059 height (cm) 2 4.50 Adult (F) 1.60 3.0216 height (cm) + 0.0795 height (cm) + 0.003 height (cm)2.537 Table 2–11 Typical Values for Total Lung Capacity Age (yr) 5 12 15 Adult (M) TLC (L) 1.84 Female adult RV (L) = 0.333 Female adult TLC (L) = 0. Typical values are shown in Table 2–11.80 ] 3 1023 Male adult TLC (L) = 0. Prediction equations are shown in Table 2–8. Table 2–10 Prediction Equations for Total Lung Capacity Child (5–16 yr) TLC (L) = [0. Table 28 Prediction Equations for Residual Volume Child (5–16 yr) RV (L) = [0.40 0.0197 height (cm) + 0. Typical values are shown in Table 2–9.00 Residual Volume to Total Lung Capacity Ratio (RV/TLC) The fraction of total lung capacity (TLC) that is taken up by residual volume (RV).20 Total Lung Capacity (TLC) The volume of gas in the lung after maximum inspiration.10 Adult (M) 1.Spirometry  35 Residual Volume (RV) That volume of gas remaining in the lungs after maximum expiration.25 6.032 height (cm)2.25 Adult (F) 5. expressed as a percent.421 Table 2–9 Typical Values for Residual Volume Age (yr) 5 12 15 RV (L) 0.70 5.0201 age 2 2.
010133 age2 + 0.7453 2 0. (L) 20.00014098 height (cm)2 Female adult ($18 yr).1933 + 0.00014815 height (cm)2 Male adult ($20 yr).06537 age + 0. Typical values for a healthy person. (L) 20. Table 2–13 Prediction Equations for Forced Expiratory Volume in 1 Second Male child (8–19 yr). (L) 21. expressed as a percentage.05916 age + 0.00018642 height (cm)2 Female adult ($18 yr).2584 2 0.8710 + 0.2082 + 0. 25 years old are shown below: FEV0.000269 age2 + 0.000172 age2 + 0. (L) 0. Prediction equations are shown in Table 2–13. Table 2–12 Prediction Equations for Forced Vital Capacity Male child (8–19 yr).000382 age2 + 0.04106 age + 0.20415 age + 0.5 sec = 60% of FVC FEV1 sec = 83% of FVC FEV2 sec = 94% of FVC FEV3 sec = 97% of FVC . (L) 20. (L) 20.00011496 height (cm)2 Forced Expiratory Volume–Forced Vital Capacity Ratio (FEV/FVC) Forced expiratory volume (timed) to forced vital capacity ratio.00014815 height (cm)2 Forced Expiratory Volume in 1 Second (FEV1) The volume of gas exhaled in 1 second during the execution of a forced vital capacity.01870 age + 0. Prediction equations are shown in Table 2–12.36  CHAPTER 2 Pulmonary Function Forced Vital Capacity (FVC) A vital capacity performed with a maximum expiratory effort sustained until empty or a exhalation time of 15 s. Prediction equations are shown in Table 2–14.5536 2 0.00018642 height (cm)2 Female child (8–17 yr).01303 age 2 0.00011496 height (cm)2 Male adult ($20 yr).3560 + 0. (L) 0.4333 2 0.000194 age2 + 0.00014098 height (cm)2 Female child (8–17 yr). (L) 20.00064 age 2 0.00361 age 2 0.004477 age2 + 0.
066 2 0. Forced Expiratory Flow 25%–75% (FEF25%–75%) Mean forced expiratory flow during the middle half of the forced vital capacity. (L/min) (0.01904 age 2 0.9267 + 0.08272 age 2 0.52490 age 2 0.0002 age2 + 0.00010345 cm2 Female adult ($18 yr).0863 + 0.013135 age2 2 0.60644 age 2 0. Prediction equations are shown in Table 2–16.016846 age2 2 0. making the practice of approximating the lower limit of normal for this parameter at 80% of the mean predicted value invalid. (L) 2. (L) 22.00018623 height (cm)2) 3 60 Male ($20). The 95% confidence interval for the FEF25%–75% has recently been shown to increase with age. (L/min) (23. Table 216 Prediction Equations for Peak Expiratory Flow Male (8–19).Spirometry  37 Table 2–14 Prediction Equations for Mean Normal FEV1/FVC Ratio (%) Male. (%) 88. Prediction equations are shown in Table 2–15.06929 age 2 0.13939 age + 0.00024962 height (cm)2) 3 60 Female ($18).5284 + 0.2066 age Female.00006982 height (cm)2 Peak Expiratory Flow (PEF) The maximum flow recorded at any point during a forced expiratory maneuver.00018623 height (cm)2) 3 60 .6181 + 0. (L) 21.7006 2 0.3670 2 0.2125 age Note: The FEV1/FVC ratio is age dependent and declines with aging in adults. The predicted lower limit of normal is approximately 9%–10% below the mean predicted value.015309 age2 + 0.001031 age2 + 0.5962 2 0.12357 age + 0.00006982 height (cm)2 Male adult ($20 yr).04995 age + 0. (%) 90.001301 age2 + 0.00010345 height (cm)2 Female child (8–17 yr). Table 2–15 Prediction Equations for Forced Expiratory Flow 25%–75% Male child (8–19 yr). (L/min) (1.809 2 0. (L/min) (20.00024962 height (cm)2) 3 60 Female (8–17). (L) 2.0523 + 0.
but multiple efforts will show the ideal rate for any given patient.165 age + 1.685 age 2 4.27 Male adult Gaw (L/sec/cm H2O) = 0.28 TGV (L) 2 0.8425 height (cm) 2 0.725 age + 0.6 3.73 . Prediction equations are shown in Table 2–19.84 Male adult (L/min) 1. However.193 height (cm) 2 0.67 Child (cm H2O/L/sec) Adult (cm H2O/L/sec) 0.2 . The ideal respiratory rate for measurement of MVV is typically 90 to 120 breaths/minute. Airway resistance and conductance both vary with thoracic gas volume (TGV). Table 2–19 Prediction Equations for Airway Conductance Child (1–5 yr) Gaw (L/sec/cm H2O) = 0.644 Child (6–18 yr) Gaw (L/sec/cm H2O) = 10[2.38  CHAPTER 2 Pulmonary Function Maximum Voluntary Ventilation (MVV) The volume of air expired in 1 minute during repetitive maximum respiratory efforts.2210] Female adult Gaw (L/sec/cm H2O) = 0.6498 log height (cm) 2 6.66 Female child (L/min) 2. Maximum values for MVV in patients with airflow obstruction may be achieved at lower respiratory rates. depending on disease severity. Table 2–17 Prediction Equations for Maximum Voluntary Ventilation Male child (L/min) 2. 5. The FEV1 3 40 will yield an approximate MVV for patients with airflow obstruction and normal inspiratory flows.772 height (cm) 2 57.9 Female adult (L/min) 0. Table 2–18 Prediction Equations for Airway Resistance Infant (cm H2O/L/sec) mean value 19. presumed to be measured at FRC.5 2 2.87 3 106 3 height (cm)22. Prediction equations are shown in Table 2–18.0 Airway Conductance (Gaw) The reciprocal of airway resistance (1/Raw).29 TGV (L) 2 0.143 3 TGV (L) 2 0.816 age 2 37.076 height (cm) 2 89.87 Airway Resistance (Raw) An effective measure of the flow resistance of the airways obtained by plethysmographic techniques. usually measured for 15 s and multiplied by 4. Prediction equations are shown in Table 2–17. the relationship between Gaw and TGV is more nearly linear than the relationship between Raw and TGV.
Transpulmonary pressure is typically calculated using esophageal pressure as a surrogate for pleural pressure. Prediction equations are shown in Table 2–23.0867 log height (cm) 2 3.24 Maximum Inspiratory Pressure (Pimax) The maximum inspiratory pressure that can be generated against an occlusion starting at or near residual volume. Prediction equations are shown in Table 2–21.5 L taken as a standardized portion of the pressure–volume curve to report as representing lung compliance. Table 2–20 Prediction Equations for Lung Compliance Infant Cl (mL/cm H2O) = 2. Prediction equations are shown in Table 2–20.0817 3 log height (cm) 2 2.Spirometry  39 Lung Compliance (Cl) An effective measure of the elastic behavior of the lungs defined as the ratio of the change in lung volume to the change in transpulmonary pressure when there is no flow. Prediction equations are shown in Table 2–22.111 age + 2. Table 2–22 Prediction Equations for Maximum Inspiratory Pressure Male (6–60 yr) Pimax (cm H2O) = 143 2 0.16 height (cm) 2 0.00102 310[2. Table 2–21 Prediction Equations for Carbon Monoxide Diffusing Capacity Child (mL/min/mm Hg) 2. Lung compliance is typically measured during passive exhalation from TLC to FRC with the segment from FRC to FRC + 0.70145] Male adult (mL/min/mm Hg) 0. .51 age Maximum Expiratory Pressure (Pemax) The maximum expiratory pressure that can be generated against an occlusion starting at or near total lung capacity.229 age + 12.55 age Female (6–60 yr) Pimax (cm H2O) = 104 2 0.3699] Adult Cl (L/cm H2O) = 0.164 height (cm) 2 0.9 Female adult (mL/min/mm Hg) 0.05 FRC (L) Carbon Monoxide Diffusing Capacity (DLco) Amount of gas diffusing across the alveolar capillary membrane per unit of pressure difference per minute.986 3 10[2.0 weight (kg) Child Cl (L/cm H2O) = 0.
03 age Female (6–60 yr) Pemax (cm H2O) = 170 2 0. Table 2–25 Assessment of Severity for Obstructive and Restrictive Pulmonary Diseases* FEV1. Percentage of Predicted Mild . obstruction means T VC and flow rates.70 Moderate 60–69 Moderately severe 50–59 Severe 35–49 Very severe .40  CHAPTER 2 Pulmonary Function Table 2–23 Prediction Equations for Maximum Expiratory Pressure Male (6–60 yr) Pemax (cm H2O) = 268 2 1. The sensitivity of a reduced FVC for restriction (confirmed by a reduced TLC on lung volumes) is approximately 60%. normal flow rates.35 * Note: The presence of a restrictive ventilatory disorder should be confirmed by measurement of lung volumes. and 2–26 show typical patterns of pulmonary function test as well as values used to assess the severity of the defects.53 age Tables 2–24. T = decreased. restriction means T VC and TLC. Table 2–24 Summary of Pulmonary Function Profile in Obstructive and Restrictive Diseases* Obstruction Restriction VC S to T (when severe) T to T T T to T T T to T T FEV1 T to T T S to c FEV1/FVC TLC S to c T to T T FRC c to c c c S to T RV c to c c c S to T RV/TLC c to c c c S to c MVV T to T T S to T T to T T S to T FEF25%275% * S = normal. . normal or increased TLC. 2–25. Typically. c = increased.
45 45–50 .40 FEV1/FVC (%) MVV (%pred) .5 5 10.25 5 2. Table 2–27 shows the dosing schedule approved by the FDA for administering a methacholine challenge test.0 5 25.60 40–60 .40 .60 40–60 . Table 2–29 shows a scheme for categorizing the PC20fev1.50 PaCO2 (mm Hg) .6s nebulization burst at FRC and a 5.0 5 * Five breaths at each dose.40 PaO2 (mm Hg room air) ■■ Bronchial inhalation challengeS Pharmacologic agents are used to identify patients with suspected airway hyperreactivity.55 40–55 .to 10s breathhold for each breath. Table 2–28 Significant Spirometry Changes Following Bronchial Challenge Test Minimum Change From Baseline (%) 220 FEV1 sGaw (specific Gaw) 240 Methacholine Results: The provocative concentration of methacholine solution that caused a 20% fall in FEV1 from baseline (PC20fev1) is calculated by interpolation when the last dose caused a greater than 20% fall.60 40–60 .Bronchial Inhalation Challenges  41 Table 2–26 General Risk of Developing Postoperative Pulmonary Complications in Patients With Abnormal Pulmonary Function Low Risk Moderate Risk High Risk VC (%pred) .025 5 0. Table 2–27 FDAApproved Dosing Schedule for Methacholine Challenge* Methacholine Concentration (mg/mL) Number of Breaths 0. The minimum change in baseline FEV1 or sGaw for a positive study is shown in Table 2–28. . with a 0.40 .
42  CHAPTER 2 Pulmonary Function Table 2–29 Categorization of Bronchial Responsiveness* PC20fev1 (mg/mL) Interpretation .16.0 Borderline bronchial hyperresponsiveness (BHR) 1.8 age Female adult REE = 66. Prediction equations are shown in Table 2–30.0 Mild BHR (positive test) . and there is a substantial postchallenge FEV1 recovery.8 weight (kg) + 5.50 70 172 2400 Women 15–18 54 162 2100 19–22 58 162 2100 23–50 58 162 2000 .5 + 13. spirometry quality is good. most cardiopulmonary stress .5 + 96 weight (kg) + 1.0–4.50 58 162 1800 Maximum Oxygen Consumption (Vo2max) The highest oxygen consumption that an individual can obtain during physical work.1.0 Moderate to severe BHR * Caveats: assumes baseline airflow obstruction is absent. Table 2–30 Prediction Equations for Resting Energy Expenditure Male adult REE = 66. Average rates of energy expenditure appear in Table 2–31.8 height (cm) 2 4. .0 Normal bronchial responsiveness 4.0 height (cm) 2 6. ■■ exerciSe phySiology Resting Energy Expenditure (REE) The minimum level of energy required to sustain the body’s vital functions in a resting state. a measure of fitness.0–16.7 age Table 2–31 Average Rates of Energy Expenditure for Men and Women Living in the United States Age Weight Height Energy Expenditure Men 15–18 61 172 3000 19–22 67 172 3000 23–50 70 172 2700 . Technically.
11 yr) (42 mL/min)/kg (50 mL/min)/kg (38 mL/min)/kg (34 mL/min)/kg # Table 2–33 Vo2 Requirements of Common Activities .Exercise Physiology  43 # # tests result in a measurement of Vo2peak. Activity Vo2 (mL/min)/kg Desk work 4–7 Driving car 4–7 Level walking (1 mph) 4–7 Sweeping floors 7–11 Making beds 7–11 Automobile repair 7–11 Wheelbarrow (100lb load) 11–14 Bicycling (6 mph) 11–14 Golfing (pulling cart) 11–14 Tennis (doubles) 14–18 Painting masonry 14–18 Golf (carrying clubs) 14–18 Digging garden 18–21 Cycling (10 mph) 18–21 .016 age # Normal Values for V o2max in Adults Male child (#13 yr) Male child (. A true Vo2max is measured when the oxygen uptake demonstrates a plateau in the face of an increasing workload. Oxygen consumption varies with activity (Table 2–33) and underlying disease (Table 2–34).032 age Female adult 2. Prediction equations and normal values are shown in Table 2–32.2 2 0.13 yr) Female child (=11 yr) Female child (. Table 2–32 Prediction Equations for # Maximum Oxygen Consumption (V o2max) Male adult 4.6 2 0.
low when severe T TT O2 pulse (max) c 2 Vd/Vt T AT T (likely to be absent when severe) T 2 Pao2 80% T c T TT 2 = Within normal range. T T = marked change.44  CHAPTER 2 Pulmonary Function Interstitial Lung Disease TT c Deconditioned T 2 . T = mild change.95% T 2 2 2 Table 2–34 Patterns of Response to Exercise Cardiac Obstructive Disease Lung Disease # T TT Vo2max # c 2 Ve/MVV HRmax (%pred) .95% Variable. .
13 Adult HRmax (bpm) = 220 2 age Heart Rate Reserve (HRR) The difference between the predicted maximum heart rate and the actual maximum exercise heart rate. 179–187 Cotes.org/sections/publications/statements/index..S. The maximum oxygen pulse is generally a reflection of the stroke volume. Hankinson. Table 2–35 Prediction Equations for Maximum Heart Rate Child HRmax (bpm) = 195 . Spirometric reference values from a sample of the general U.Suggested Reading  45 Maximum Heart Rate (HRmax) The highest heart rate attained during maximum exercise. B.. Prediction equations are shown in Table 2–35. Eur Respir J 26 (2005). population. The calculation of maximum heart rate reserve is HRR = predicted HRmax 2 observed HRmax. Odencrantz. J. J. 948–968.thoracic. R. The prediction equation for maximum oxygen pulse is MOP (mL/beat) = predicted VO 2max (mL/min) predicted HRmax (mL/min) SuggeSted reading American Thoracic Society/European Respiratory Society Task Force. Standardisation of lung function testing: Interpretive strategies for lung function testing. E. American Thoracic Society: Guidelines for Pulmonary Function Testing. Maximum Oxygen Pulse (MOP) The quotient of predicted maximum oxygen consumption and predicted maximum heart rate. Lung Function: Assessment and Application in Medicine. Am J Respir Crit Care Med 159:1 (January 1999). L. Downloads available from: http://www. J. K. . and Fedan. 1993. Oxford: Blackwell Scientific Publications.html.
. J. 5th ed. N. Sue. and Whipp. 2004.. K. B. Stringer. J. London: Balliere Tindall. W. B. 4th ed. Philadelphia: Lippincott. Wasserman.. Williams and Wilkins.. and Pride. Principles of Exercise Testing and Interpretation: Including Pathophysiology and Clinical Applications.46  CHAPTER 2 Pulmonary Function Hughes. D. . M. 1999. Hansen. Lung Function Tests: Physiological Principles and Clinical Application.
CHAPTER Physiologic Monitoring 3 .
Under steadystate conditions. See oxygen consumption on page 92. that the net exchange of nitrogen is negligible because of its very low solubility.0: Equation for Fio2 = 1.48  CHAPTER 3 Physiologic Monitoring ■■ Gas ExchanGE The equations in this section express the relationships that exist during gas exchange in the steady state.0: # # 1 2 FECO2 2 FEO2 VO2 5 VE c FIO2 a b 2 FEO2 d 1 2 FIO2 # # VO2 5 VE 1FIO2 2 FEO22 where # Ve = exhaled minute volume (mL/min STPD) Fio2 = fraction of oxygen in inspired gas FEO2 = fraction of oxygen in mixed exhaled gas FECO2 = fraction of carbon dioxide in mixed exhaled gas . that there is no carbon dioxide in the inspired gas. All fractional gas concentrations are calculated on a dry gas basis. They are based on the following two assumptions: 1. Oxygen Uptake The rate at which oxygen is removed from alveolar gas by the blood.1. oxygen uptake equals oxygen consumption (the rate at which oxygen is metabolized). # Abbreviation: V o2 Units: mL/min (STPD) Normal value: 240 mL/min (adults) or 100–180 mL/min/m2 (children or adults) 6–8 mL/min/kg (infants) Equation for Fio2 . and 2.
The time required to reach a given carbon dioxide concentration (% CO2) is given by % CO2 3 V t5 # VCO2 3 100 3 N . # Abbreviation: VCO2 Units: mL/min (STPD) Normal value: 192 mL/min (adults) or 80–144 mL/min/m2 (children and adults) 5–6 mL/kg/min (infants) Equation: # # VCO2 5 VE 3 FECO2 # # VA 3 PACO2 VCO2 5 PB 2 PAH2O # # VCO2 1PB 2 PAH2O2 RE 1PB 2 PAH2O2VO2 # VA 5 5 PACO2 PACO2 where # Ve = exhaled minute volume (mL/min STPD) FECO2 = fraction of carbon dioxide in mixed exhaled gas # Va = alveolar ventilation (mL/min STPD) PACO2 = partial pressure of alveolar carbon dioxide (mm Hg). This value is often assumed to be equal to arterial carbon dioxide tension (Paco2) Re = respiratory exchange ratio Pb = barometric pressure (mm Hg) PAH2O = partial pressure of water in alveolar gas (mm Hg).Gas Exchange  49 Carbon Dioxide Output Carbon dioxide output is a function of the amount of that gas produced by metabolism and the level of alveolar ventilation. During rebreathing experiments or when individuals are confined to an enclosed area. the carbon dioxide concentration rises in proportion to the rate of carbon dioxide production. The equation relating these variables may also be solved for alveolar ventilation. This value is 47 mm Hg for gas saturated with water vapor at 378C.
This ratio depends on the type of substrate being metabolized.0 (i.7. VCO2 was estimated at 0. the respiratory quotient equals 1.50  CHAPTER 3 Physiologic Monitoring where t = time % CO2 = ambient CO2 level (%) V = volume of enclosure # VCO2 = CO2 production rate N = number of individuals For example. C6H12O2 + 6 O2 S 6 COCO2 + 6 H2O). For fat RQ is approximately 0.75 ft3/h so that the above equation reduced to t(hours) = 0.04 V/N.e. and for protein RQ is about 0. For glucose. Under . Abbreviation: Paco2 Units: mmHg Normal value: 35–45 mm Hg Equation: PACO2 5 where # VCO2 = carbon dioxide output # VE = exhaled minute ventilation Vd/Vt = Dead space ratio # VD VE 3 a 1 2 b VT # 0. at one time the standard for ambient carbon dioxide levels # aboard Navy submarines was 3%..863 3 VCO2 Respiratory Quotient The molar ratio of carbon dioxide production to oxygen consumption. Alveolar and arterial Pco2 can be assumed to be equal.8. Alveolar Carbon Dioxide Equation Alveolar partial pressure of carbon dioxide is directly proportional to the amount of carbon dioxide produced by metabolism and delivered to the lungs and inversely proportional to the alveolar ventilation.
80–0. fat. Abbreviation: Pio2 Units: mm Hg (torr) Equation: PIO2 5 1PB 2 PIH2O2FIO2 . and protein is metabolized to produce a respiratory quotient of 0. Abbreviation: Re Units: dimensionless Normal value: 0.8 Equations: # VCO2 RE 5 # VO 2 RE 5 FECO2 1 2 FECO2 2 FEO2 FIO2 a b 2 FEO2 1 2 FIO2 where # VCO2 = carbon dioxide output # VO2 = oxygen uptake FECO2 = fraction of carbon dioxide in mixed exhaled gas FIO2 = fraction of inspired oxygen FEO2 = fraction of oxygen in mixed exhaled gas Partial Pressure of Inspired Oxygen The dry gas pressure of oxygen in inspired air.8–0.85 Respiratory Exchange Ratio The ratio of carbon dioxide output to oxygen uptake as determined by the analysis of mixed exhaled gas. Abbreviation: RQ Units: dimensionless Normal value: 0.85. a mixture of glucose.Gas Exchange  51 steadystate conditions.
which would produce the same inspired oxygen tension.13 0.000 (m) 0 305 610 914 1.000 10.000 24.925 8.000 22. Tables 3–1 and 3–2 along with Figures 3–1 through 3–4 show various measurements of partial pressure as well as the effects of altitude on such measurements.15 0.12 0.877 5.000 4.706 7.) Fio2 = fraction of oxygen in inspired gas Note: To calculate Pio2 during mechanical ventilation.17 0.524 1.000 14.000 30.14 0.000 3.000 2. .658 4. Table 3–1 Effect of Altitude on Inspired Oxygen Tension Altitude (ft) 0 1. mean airway pressure (in mm Hg) should be added to barometric pressure.000 26.000 20.09 0.05 *Fio2 at sea level.267 4.07 0.000 5.21 0.16 0.829 2.315 7.486 6.219 1.52  CHAPTER 3 Physiologic Monitoring where Pb = barometric pressure (mm Hg) Pih2o = partial pressure (mm Hg) of water in inspired gas (This value is 47 mm Hg for gas saturated with water vapor at 378C.18 0.534 9.08 0.438 3.06 0.2 0.000 6.10 0.19 0.11 0.07 0.19 0.096 6.048 3.000 28.000 8.144 Barometric Pressure (torr) 760 733 707 681 656 632 609 564 523 483 446 412 379 349 321 294 270 247 226 (kPa) 101 97 94 91 87 84 81 75 70 64 59 55 50 46 43 39 36 33 30 Inspired Oxygen Tension (torr) (kPa) 149 20 143 19 138 18 133 18 127 17 122 16 117 16 108 14 99 13 91 12 83 11 76 10 69 9 63 8 57 8 52 7 47 6 42 6 37 5 Equivalent Fio2* 0.000 18.000 16.000 12.
5 So2. mm Hg 80–100 65–75 19.3. mm Hg 35–45 34–38 10. W.1–29.5–7. mEq/L 22–+2 22–+2 25.457.Gas Exchange  53 Table 3–2 Comparison of BloodGas Values at Altitude and at Sea Level Sea Level Denver Mt Everest 1609 m 8400 m pH 7.35–7.60 Pco2.7–29.7 HCO2 . mm Hg 800 Air O2 157 Alveolus CO2 40 H2O 47 C2 102 Artery O2 93 Blood Vein O2 40 CO2 47 H2O 47 600 CO2 O 3 H2O 10 CO2 40 H2O 47 400 N2 592 N2 570 N2 570 N2 570 200 0 Figure 3–1 Partial pressures of gas in air at sea level (BP = mm Hg).45 7. P.3–15. et al.9–12 3 be.95 92–94 34–69.7 Po2. . M. mEq/L 22–26 22–26 9.45 7. % . NEJM 360 (2009). 140–149.2 Data from Grocott.
5–6.3) (0.0–14.2) Figure 3–2 Normal partial pressures of respired gases.9) 573 (76. .3) (53) PAN2 PAH2O Mixed Venous Blood Gas mm Hg (kPa) ¯ PVO2 ¯ PVCO2 ¯ PVN2 Arterial Blood Gas mm Hg (kPa) 37–42 (4.1) PaN2 573 (76.2) PaO2 90–110 (11.7) ALVEOLAR GAS mm Hg (kPa) 116 28 568 47 (15.3 596 5 (21.54  CHAPTER 3 Physiologic Monitoring Inspired Gas mm Hg (kPa) Mixed Expired Gas mm Hg (kPa) ¯ PEO2 ¯ PECO2 ¯ PEN2 ¯ PEH2O PIO2 PICO2 PIN2 PIH2O 158 0.6) 40–52 (5.5) (6.3–6.04) (79.6) PaCO2 34–46 (4.4) (3.3) PAO2 PACO2 103 570 47 40 (137) (758) (6.0) (0.7) (75.9–5.
and arterial oxygen tension (Fio2 = 0. .Gas Exchange  55 (Meters) 150 140 130 120 110 100 90 Pressure (mm Hg) 80 70 0 1000 2000 3000 4000 20 18 16 14 12 10 8 6 4 2 0 (kPa) PIO2 PAO2 mild 50 40 30 20 10 0 hypoxemia 60 PaO2 PaO2 PaO2 PaO2 moderate severe 2 4 Altitude (thousands of feet) 6 8 10 12 14 16 Figure 3–3 The effect of altitute on inspired. alveolar.21).
8 0. Abbreviation: Pao2 Units: mm Hg (torr) Normal value (room air): 102 at sea level Equation: PAO2 5 PIO2 2 PACO2 c FIO2 1 a < PIO2 2 PACO2 RE 1 2 FIO2 bd RE .3 0.5 0.56  CHAPTER 3 Physiologic Monitoring Altitude (thousands of feet above sea level) 1.9 0.4 0. Alveolar Oxygen Tension The following equation represents the mean alveolar oxygen tension.0 0.7 0.2 100 200 300 400 500 600 700 Arterial Oxygen Tension (mm Hg) 35 25 20 15 12 8 4 0 Fraction of Inslpired Oxygen Figure 3–4 The effect of altitude on Pao2 during oxygen administration.6 0. Figure 3–5 illustrates a nomogram for the equation.
. A straight line connecting Paco2 and Fio2 will intersect the resulting Pao2 and the predicted Pao2. For example.Gas Exchange  57 where Pio2 = partial pressure of oxygen in inspired gas (mm Hg) Paco2 = partial pressure (mm Hg) of carbon dioxide in alveolar gas (this value is often assumed to be equal to arterial carbon dioxide tension [Paco2]) Fio2 = fraction of oxygen in inspired gas Re = respiratory exchange ratio (mm Hg) (mm Hg) 600 PAO2 PaO2 FIO2 100 (%) 550 500 450 400 350 300 250 200 150 100 450 (mm Hg) 90 80 70 60 50 40 30 20 PaCO2 90 80 70 60 50 40 30 20 400 350 300 250 200 150 100 Figure 3–5 Alveolar air equation nomogram (assuming sea level and R = 0.8 and virtual shunt of 5%). a Paco2 of 40 mm Hg and an Fio2 of 70% will result in a Pao2 of approximately 450 mm Hg and a predicted Pao2 of about 370 mm Hg.
It is most stable when it is less than 0. see Figures 3–6 and 3–7. and the Pao2 is less than 100 mm Hg.58  CHAPTER 3 Physiologic Monitoring Arterial–Alveolar Oxygen Tension Ratio An index of gas exchange function that has been shown to be more stable than the alveolar–arterial oxygen tension gradient with changing values of inspired oxygen concentration.74–0. the Fio2 is greater than 0.55.82 (lower limits of normal for men) Equation: P1a> A2 O2 5 P1a> A2 O2 < PIO2 2 PACO2 c FIO2 1 a PaO2 PaO2 PaCO2 PIO2 2 RE 40% 35% 1 2 FIO2 bd RE 100 PaO2 on O2 (mm Hg) 80 28% 24% 60 40 20 30 PaO2 on air (mm Hg) 40 50 60 70 Figure 3–6 Graph relating the expected Pao2 during oxygen administration based on the measured Pao2 on room air. (For graphs related to this ratio.30.) Abbreviation: P(a/a)o2 Units: dimensionless Normal value: 0. .
If the measured Pao2 is 225 mm Hg.2 20 0.0 80 (%) 550 500 450 400 350 300 250 200 150 100 50 0 (mm Hg) 90 80 70 60 50 40 30 20 10 5 PaCO2 (kPa) 30 0 100 200 PaO2 (mm Hg) 300 400 500 600 Figure 3–7 Arterial to alveolar oxygen tension ratio nomogram.8 70 0.9 1. a Paco2 of 40 mm Hg and an Fio2 of 70% result in a Pao2 of about 450 mm Hg.3 30 0. this value is often assumed to be equal to Paco2 Paco2 = partial pressure of carbon dioxide in arterial blood Fio2 = fraction of oxygen in inspired gas Re = respiratory exchange ratio FIO2 PaCO2 100 90 80 70 60 50 40 20 (mm Hg) 600 PAO2 PAO2 80 75 70 65 60 55 50 45 40 35 30 25 20 15 10 5 0 (kPa) 0 0.Gas Exchange  59 where Pao2 = partial pressure of oxygen in arterial blood (mm Hg) Pio2 = partial pressure of oxygen in inspired gas (mm Hg) Paco2 = partial pressure of carbon dioxide in alveolar gas (mm Hg).5.7 60 0. For example.4 PaO2 (kPa) 40 0. The arterialalveolar ratio is represented by the diagonal line connecting the origin of the graph (Pao2 = 0. Pao2 = 0) and the point representing the given Pao2 and Pao2. A straight line connecting Paco2 and Fio2 will intersect the resulting Pao2. the P(a/a)o2 ratio is 0. .5 0.1 10 0.6 50 0.
The alveolar–arterial oxygen gradient increases # # with age mainly due to progressing V>Q mismatch.9333 2 0. Abbreviation: P(a–a)o2 Units: mm Hg Normal value: 7–14 (while breathing 21% O2) Equation: P1A–a2 O2 5 PIO2 2 PACO2 c FIO2 1 a P1A–a2 O2 < PIO2 2 PACO2 2 PaO2 RE 1 2 FIO2 b d 2 PaO2 RE where Pio2 = partial pressure of oxygen in inspired gas (mm Hg) Paco2 = partial pressure (mm Hg) of carbon dioxide in alveolar gas (this value is often assumed to be equal to Paco2) .60  CHAPTER 3 Physiologic Monitoring Prediction Equation for Normal P(a/a)O2 While Breathing Room Air: Sitting: P(a/a)o2 = 0.9333 2 0. The results of this calculation are limited to giving only a qualitative estimate of the degree of shunting and will vary with changes in the inspired oxygen concentration and cardiovascular status.00406 age (yr) The patient’s current P(a/a)o2 may be used to estimate the Fio2 required to obtain a desired Pao2 using the equation: a PaO2 desired b 1 PaCO2 desired P1a> A2 O2 PB 2 47 FIO2needed 5 where Pb = barometric pressure in mm Hg Alveolar–Arterial Oxygen Tension Gradient This method of estimating the degree of intrapulmonary shunting assumes that the arterial oxygen tension is greater than 150 mm Hg.0026 age (yr) Supine: P(a/a)o2 = 0.
27 age* $0.0026 age** Severe $55. arterial oxygen tension (using normal values) can be expressed as PaO2 5 PAO2 5 PB 2 147 1 PaCO22 < 673 mm Hg Any reduction in actual arterial oxygen tension from the theoretical value represents venoustoarterial shunting.Gas Exchange  61 Paco2 = partial pressure of oxygen in arterial blood (mm Hg) Fio2 = fraction of oxygen in inspired gas Re = respiratory exchange ratio Note: Another estimate of shunt can be derived by assuming a value for ideal alveolar–arterial equilibration while breathing 100% oxygen. Age in years. .2 2 0.55. each 100 mm Hg reduction in actual Pao2 below the theoretical Pao2 represents a 5% shunt.482 2 0. for supine posture.27 age (yr) Supine: P(a–a)o2 = 0.27 age* #35 + 0.0026 age** Extreme .27 age* Mild $83. change age coefficient to 0. Under these conditions.27 age* .0026 age** Normal $97.798 2 0.27 age* . For practical purposes.49 + 0.0026 age** * ** Age in years.2 2 0.27 age* $0.27 age* #7 + 0.2 2 0.27 age* #49 + 0.0. The clinical equation is thus % shunt < 673 2 PaO2 20 Prediction Equations for Normal P(a–a)O2 While Breathing Room Air: Sitting: P(a–a)o2 = 0.933 2 0.42.482 2 0. 3–4.27 age* $0. and 3–5 show equations and ranges to characterize the severity of oxygenation impairment.664 2 0.2 2 0. for supine posture.27 age* #21 + 0.42 age (yr) Tables 3–3. change age coefficient to 0.2 2 0. Table 3–3 Prediction Equations for Determining Oxygenation Impairment for Sitting Subjects P(a/a)o2 Impairment Pao2 P(a–a)o2 (mm Hg) (Dimensionless) (mm Hg) $0.0026 age** Moderate $69.00406.
A ratio of 200 or less correlates with a shunt fraction of 20% or more but is generally a crude indicator of shunt.80 Moderate hypoxemia .60 90 . but is subject to variability due to differing values of arterial carbon dioxide tension.62  CHAPTER 3 Physiologic Monitoring Table 3–4 Assessment of Hypoxemia in Adults and Children* Pao2 (mm Hg) Normal 97 Acceptable .33 3 age (yr) Oxygenation Ratio The ratio of arterial oxygen tension to the fraction of inspired oxygen (where Fio2 is expressed as a decimal. This ratio is easier to calculate than either the P(a–a)o2 or the P(a/a)O2.80 70 . Abbreviation: Pao2/Fio2 Units: dimensionless Normal value: 350–470 . Table 3–5 Assessment of Hypoxemia in Newborn and Elderly Patients* Age (yr) Acceptable Range of Pao2 Newborn 40–70 60 . 21% oxygen.70 80 .80 Mild hypoxemia .40 * Sea level.50 * Limits of hypoxemia for elderly patients are determined by subtracting 1 mm Hg for each year over 60. Normal: Pao2 < 102 2 0. 30% = 0.3).60 Severe hypoxemia .
2 mL/kg ideal body weight Vd/Vt = 0. Abbreviation: Vd Units: mL (BTPS) Normal value: Vt = 2. or (3) too much gas reached the alveoli in proportion to their perfusion. Figure 3–8 shows the correlation between minute ventilation and carbon dioxide at different values of physiologic dead space. Physiologic dead space is often expressed as a ratio of dead space volume to tidal volume (Vd/Vt). (2) it reached alveoli with no perfusion.35 for 5–6 hours is one criterion for ECMO.Gas Exchange  63 Oxygenation Index An index of oxygenation status often used to assess infants before treatment with extracorporeal membrane oxygenation (ECMO). The value of the oxygenation index correlates with mortality in pediatric acute respiratory failure. Abbreviation: OI Units: cm H2O/mm Hg Normal Value: 0 Equation: OI 5 where Paw 3 FIO2 3 100 PaO2 Paw = mean airway pressure (cm H2O) Fio2 = fraction of inspired oxygen (as decimal) Pao2 = arterial oxygen tension (mm Hg) Physiologic Dead Space (Bohr Equation) The volume of inspired gas that is not effective in arterializing the venous blood.40 Equation: VD 5 PACO2 2 PECO2 3 VT PACO2 . an index value of . The three main reasons for its ineffectiveness are (1) it never reached alveoli.20–0. In these patients.
and carbon dioxide output of 112 mL/min/m2). 37°C. where Vt = tidal volume (mL BTPS) Paco2 = partial pressure (mm Hg) of carbon dioxide in alveolar gas (this value is often assumed to be equal to arterial carbon dioxide tension [Paco2]) PECO2 = partial pressure of carbon dioxide in mixed exhaled gas (mm Hg) Prediction Equation: # PaCO2 VD actual VE 5 3 0.33 # 3 VT 40 pred VE where pred = minute ventilation predicted from Radford nomogram Paco2 = arterial carbon dioxide tension (mm Hg) .64  CHAPTER 3 Physiologic Monitoring PaCO2 (kPa) 6 7 30 3 4 5 8 9 10 Minute Ventilation (L/min/square meter) 20 80 70 VD (%) VT 10 50 40 30 20 60 0 20 30 40 PaCO2 (mm Hg) 50 60 70 80 Figure 3–8 Graph relating minute ventilation and Paco2 for different values of physiologic dead space (assuming Pb = 760 mm Hg.
40 Equation: VD 5 0. Abbreviation: Vd/Vt Units: dimensionless Normal value: Vd/Vt = 0.01061PaCO2 2 ETCO22 1 0. 288–329) described and validated an equation to obtain the dead space ratio from clinically available data. Abbreviations: Cao2 (arterial oxygen content) CVO2 (mixed venous oxygen content) Cc9o2 (pulmonary end capillary oxygen content) Units: vol% (mL O2/dL blood) Normal value: Cao2 = 20. Recently Frankenfield et al.32 1 0.00151age2 VT Paco2 = arterial carbon dioxide tension (mm Hg) ETco2 = exhaled end tidal carbon dioxide (mm Hg) RR = respiratory rate (breaths per minute) Age = age of patient (years) where Oxygen Content of Blood The following equations give the total quantity of oxygen in the blood.20–0. although there are devices that can obtain approximations based on volume exhaled and the curve obtained from the end tidal carbon dioxide. This is technically difficult in daily practice.Gas Exchange  65 Clinical Calculation of Dead Space Classically. this is also not widely available.0031RR2 1 0. to calculate dead space requires collection of exhaled gas to measure the partial pressure of carbon dioxide. (Crit Care Med 38 (2010). CVO2 = 15 . This includes the quantity of oxygen dissolved in the plasma plus the quantity of oxygen bound to the hemoglobin.
0.0031 3 PVO2 ) Cc9o2 = (Hb 3 1. 0.. if the metabolic demands of the body are assumed to be constant.0031 = a constant derived using the Bunsen solubility coefficient of oxygen in blood (i.39 or 1. where the oxygen saturation is assumed to be 100%. That is.0031 mL of oxygen can be dissolved for each mm Hg of oxygen tension on the blood) Pao2 = partial pressure of oxygen in arterial blood (mm Hg) PVO2 = partial pressure of oxygen in mixed venous blood (mm Hg) Pc9o2 = partial pressure of oxygen in endpulmonary capillary blood (mm Hg) (often assumed to be equal to the partial pressure of oxygen in alveolar gas (Pao2)) Note: The pulmonary end capillary oxygen content reflects the maximal oxygen carrying capacity. Abbreviation: C(a– V )O2 Units: vol% (mL O2 per dL blood) .66  CHAPTER 3 Physiologic Monitoring Equations: Cao2 = (Hb 3 1.34 3 O2sat) + (0.0 when the oxygen tension of the blood is above 150 mm Hg. a decrease in cardiac output will cause an increase in arteriovenous oxygen difference. This value is assumed to be 1.34 3 O2sat) + (0.e.0031 3 Pao2) CVO2 = (Hb 3 1. It is also used as an indication of cardiac output.0031 3 Pc9o2) where Hb = hemoglobin content in g % (g Hb/dL blood) (normal value = 15 g %) 1. for each 100 mL of blood. Arteriovenous Oxygen Content Difference The difference between the arterial and venous oxygen content is an indication of the amount of oxygen the body is consuming.36) O2sat = hemoglobin saturation expressed in decimal form.34 3 O2sat) + (0.34 = a constant describing the amount of oxygen (mL at STPD) that can be carried by 1 g Hb when it is fully saturated (some authorities use 1.
Gas Exchange  67 Normal value: 4.5 (patients that are critically ill but stable) Equation: C1a 2 V2 O2 5 CaO2 2 CVO2 where Cao2 = arterial oxygen content (mL/dL) CVO2 = mixed venous oxygen content (mL/dL) Ventilation–Perfusion Ratio This equation relates the factors that determine the adequacy of alveolar ventilation. It assumes that arterial and mixed venous blood gas samples are drawn simultaneously.8 Equation: where RE 1PB 2 PAH2O21CaO2 2 CVO22 # # VA>QC 5 PACO2 3 100 # VA = alveolar ventilation # QC = pulmonary blood flow Re = respiratory exchange ratio Pb = barometric pressure (mm Hg) Pah2o = partial pressure (mm Hg) of water in alveolar gas (this value is 47 mm Hg for gas saturated with water vapor at 378C) Cao2 = arterial oxygen content (mL/dL) CVO2 = mixed venous oxygen content (mL/dL) Paco2 = partial pressure (mm Hg) of alveolar carbon dioxide (this value is often assumed to be equal to arterial CO2 tension [Paco2]) . # # Abbreviation: V>Q Units: dimensionless Normal value: 0. This should be done midway through the expired gas collection if Re is being calculated.5–4.5–6.0 (children and adults) 2.
Table 3–6 shows “normal” values for respiratory gas exchange. the arteriovenous content difference.68  CHAPTER 3 Physiologic Monitoring VenoustoArterial Shunt (Classic Form) The collection of data for the shunt calculation is usually done with the patient placed supine while breathing 100% oxygen. This assumption is valid because the test is done with an inspired oxygen fraction of 1. with the assumption that arterial hemoglobin is fully saturated with oxygen when the arterial oxygen tension is greater than 150 mm Hg.5 vol%. C(a– V2 O2 is assumed to be 3.0. CVO2 = mixed venous oxygen content (mL/dL) # QS = shunted portion of cardiac output # QT = total cardiac output Cc9o2 = oxygen content of pulmonary endcapillary blood (mL/dL) Cao2 = oxygen content of arterial blood (mL/dL) VenoustoArterial Shunt (Clinical Form) # # Abbreviation: QS>QT Units: % Normal value: 2–5 (children and adults) . # # Abbreviation: QS>QT Units: % Normal value: 2–5 (children and adults) Equation: where # Cc¿ O2 2 CaO2 QS # 5 Cc¿ O2 2 CvO2 QT # # The clinical shunt equation is a rearrangement of the classic QS>QT equation. In most circumstances in which this form of the equation is used. which usually results in an arterial oxygen tension greater than 150 mm Hg. Figure 3–9 shows the relations between arterial blood tension and inspired oxygen concentration for different values of shunt.
0031 QT where # QS = shunted portion of cardiac output # QT = total cardiac output Pao2 = partial pressure of oxygen in alveolar gas (mm Hg) Pao2 = partial pressure of oxygen in arterial blood (mm Hg) 0.. for each 100 mL of blood at BTPS.0 mm Hg of oxygen tension) C(a– V )o2 = arteriovenous oxygen content difference (mL/dL) .Gas Exchange  69 kPa 60 50 Arterial Oxygen Tension 40 30 20 10 100 30% 50% 0 20 30 40 50 60 70 80 90 Inspired Oxygen Concentration (%) 100 mmHg 400 Virtual Shunt 0% 5% 10% 15% 300 20% 200 25% 0 Figure 3–9 Graph relating Pao2 and inspired oxygen concentration for different values of virtual shunt.3 kPa). Shaded lines represent hemoglobin concentration range of 10–14 g/dL and Paco2 range of 25–40 mm Hg (3.0031 = a constant derived using the Bunsen solubility coefficient for oxygen in blood (i.0031 mL of oxygen can be dissolved for each 1. Equation: # 1PAO2 2 PaO220.e.0031 QS # 5 C1a–V2 O2 1 1PAO2 2 PaO220.3–5. 0.
05–0. as a Decimal Fraction) from Oxygen Tension (Po2.385 3 ln1SO21 2 12 21 1 3. Ventilation–perfusion ratio (V/Q) 0. 0.400g 1 12 21 2 (3–1) 1SO22 6 6 d (3–2) . .96): SaO2 5 1fPO3 1 150 3 PO22 21 3 23.6 0.70  CHAPTER 3 Physiologic Monitoring Table 3–6 Respiratory Gas Exchange and Pressures Measurement Symbol Adult Flows .8 Venous admixture .32 2 172 3 SO22 21 2 2 Po2 from So2 (for So2 . Pulmonary capillary flow (Qc) 75 .15 105 35 573 80 36 583 24 1 10 Units mL/kg/min mL/kg/min mm Hg mm Hg mm Hg mm Hg mm Hg mm Hg mm Hg mm Hg mm Hg Equations for Human BloodOxygen Dissociation Computation The following equations assume blood temperature = 378C and pH = 7. 60 Alveolar ventilation (Va) . .40. 0.05 Shunt flow/total flow Qs/Qt Alveolar gases 105 Oxygen (Pao2) 40 Carbon dioxide (Paco2) 568 Nitrogen (Pan2) Arterial gases 95 Oxygen (Pao2) 41 Carbon dioxide (Paco2) 575 Nitrogen (Pan2) Gas differences 10 Oxygen P(a–a)o2 1 Carbon dioxide P(a–a)co2 7 Nitrogen P(a–a)n2 Infant 120 200 0. Oxygen Saturation (So2. in mm Hg): PO2 5 exp c 0.
2. Acidemia Hyperthermia Hypercarbia Increased 2. loge) Correction of Po2 to pH = 7. Step 3: Use equation (3–2) above to calculate Po2 from the measured So2. 4.) Factors shifting the hemoglobinoxygen dissociation curve to the right (decreased affinity): 1. 4.2 and 0. Step 5: P50 5 26.1 3 1pH 2 7. use this value as Po2 (obs) in equation (3–4) below. Alkalemia Hypothermia Hypocarbia Decreased 2. 2.3diphosphoglycerate (2.8.3DPG . 3. Step 4: Use equation (3–3) above to estimate Po2 at pH = 7.4 from the measured Po2 and pH. use this value as Po2 (std) in equation (3–4) below.402 5 PO2 3 e1.7 3 PO2 1obs2 PO2 1std2 (3–4) Hemoglobin Affinity for Oxygen (See Figure 3–10 and Figure 3–11. Step 2: Measure the Po2 and pH of the sample at 378C. 3.Gas Exchange  71 where ln represents the natural logarithm (i..42 (3–3) Computation of P50: Step 1: Obtain a sample of blood with a measured saturation between 0.40 (Bohr Effect): PO2 1at 7.3DPG) Factors shifting the hemoglobinoxygen dissociation curve to the left (increased affinity): 1.e.
0 6.0 10.40. .0 7.0 2.72  CHAPTER 3 Physiologic Monitoring PO2 SO2 PO2 700 400 (mm Hg) (%) 200 100 70 60 50 45 40 35 30 25 80 70 60 50 40 20 30 20 10 100 90 (mm Hg) (%) 100 99 98 97 96 95 94 93 92 60 91 S O2 200 150 130 110 100 95 90 85 80 75 70 (kPa) (%) 100 20.0 4.5 90 80 70 60 50 40 PO2 SO2 (kPa) (%) 100 100 50 30 99 20 15 14 13 12 11 98 97 96 95 94 9 93 92 8 91 PO2 SO2 10 65 30 20 10 15 Figure 3–10 Nomogram relating Po2 and oxygen saturation (So2) at 37°C.0 3. and base excess = 0.5 6.5 3.5 2.0 5.5 4.0 8.0 1.5 5. pH = 7.
P50: An index of the affinity of hemoglobin for oxygen. and pH = 7. It is defined as the oxygen tension at which 50% of the hemoglobin is saturated at 37°C. The normal adult P50 is approximately 27 mm Hg.4. ■■ BloodGas analysis: TradiTional and ThE sTEwarT METhod Henderson–Hasselbalch Equation This equation expresses the blood acid–base relationship in terms of the bicarbonate ion to carbonic acid ratio. It is based on the chemical equation H2CO3 S H1 1 HCO2 3 which describes the dissociation of carbonic acid into hydrogen ions and bicarbonate ions. A reduced P50 means an increased hemoglobin affinity for oxygen. The law of mass action defines the dissociation constant (Ka) of carbonic acid as Ka 5 fH1 g fHCO2g 3 fH2CO3g The carbonic acid concentration is dependent on the amount of dissolved carbon dioxide in the blood. Pco2 = 40 mm Hg.03 mmol/L/mm Hg) and the partial pressure of carbon dioxide in the blood (Pco2) (see Figure 3–16). .BloodGas Analysis: Traditional and the Stewart Method  73 100 % Oxygen Saturation 85 80 75 60 40 20 O2 tensions of which cyonosis first observed Adult Fetal 10 20 30 40 50 60 70 80 90 100 200 300 400 500 600 Oxygen Tension (mm Hg) Fetal Adult Dangerous to infant retina Figure 3–11 Oxyhemoglobin dissociation curves. Thus. The amount of dissolved carbon dioxide (mmol/L) is dependent on its solubility coefficient (0.
1 1 log a 5 6. Table 3–8 shows the formulas used to calculate the expected compensation in simple acid–base disorders. and bicarbonate concentration.40 40 1 SD 7.34 . all measurable quantities: 2log fH1g 5 2log Ka 2 log a pH 5 6. flow charts.03 3 40 6 normal pH 5 7.4. Figures 3–12..03PCO2 This equation can now be rearranged to a more useful form that relates plasma hydrogen ion concentration. Substituting normal values for HCO2 3 (24 mmol/L) and Paco2 (40 mm Hg) in the above equation yields 24 b 0. Table 3–7 shows the ranges for pH and Paco2 at sea level.38–7.03PCO2 b fHCO2g 3 The value of 2log Ka (i.35–7.3 0.42 38–42 2 SD 7. Table 3–7 Ranges and Nomenclature for pH and Paco2 pH Paco2 (mm Hg) Normal range Mean 7. 3–14.74  CHAPTER 3 Physiologic Monitoring the above equation can be written as Ka 5 fH1g fHCO2g 3 0.03PCO2 b fHCO2g 3 The hydrogen ion concentration is more commonly expressed in terms of pH (negative log of hydrogen ion concentration) as follows: pH 5 2 log Ka 1 log a fHCO2g 3 b 0.46 Acidemia #7.45 35–45 Alkalemia $7.e.1.03PCO2 fH1 g 5 Ka a 0.1 1 1. 3–13. PCO2. PKa) is 6. and maps to interpret acid–base disorders. and 3–15 depict nomograms.
7 3 HCO3) + 21 Paco2 = 40 + (0.24 h) DH+ = 0.0 mEq/L/ c 10 torr Paco2 Chronic (.8 3 DPaco2 DpH = 0.12 h) DH+ = 0.008 3 DPaco2 HCO–3 = ([Paco2 2 40]/10) + 24 HCO–3 c 0.BloodGas Analysis: Traditional and the Stewart Method  75 Table 3–8 Expected Compensation for Simple Acid–Base Disorders Disorder and pH Initial Change Compensatory Compensation Change – T Metabolic acidosis T Paco2 T HCO3 Paco2 = (1.24 h) DH+ = 0. 2 Paco2 < last two digits of pH Paco2 T 1.6 3 standard base excess) Paco2 c 0.5 3 HCO) + 8 . c .0 mEq/L HCO–3 Metabolic alkalosis c HCO–3 c c Paco2 – Paco2 = (0.5 mEq/L/ c 10 torr Paco2 Respiratory alkalosis T Paco2 T HCO–3 c Acute (.17 3 DPaco2 HCO–3 = 24 2([40 2 Paco2]/2) HCO–3 T 2.0–1. c N.1–5.003 3 DPaco2 HCO–3 = ([Paco2 2 40]/3) + 24 HCO–3 c 1.1–3.5 torr/ T 1.8 3 DPaco2 HCO–3 = 24 2([40 2 Paco2]/5) HCO–3 T 0–2.0 mEq/L/ T 10 torr Paco2 Anion Gap N.3 3 DPaco2 DpH = 0.5–1.0 torr/ c 1 mEq/L HCO–3 T Respiratory acidosis c HCO–3 c Paco2 Acute (.1–1. T N N.0 mEq/L/ T 10 torr Paco2 Chronic (12–72 h) DH+ = 0.
0 7.4 7.8 7.6 1.2 7.1 7.0 9.5 4.5 3.5 5.0 7.7 7.6 7.5 2. bicarbonate concentration (HCO–3).0 10 12 14 16 18 15 20 25 30 35 40 50 60 70 80 90 100 110 120 150 Figure 3–12 Modified SiggaardAnderson nomogram relating blood pH.0 6.0 2.3 7.0 6.9 7. . Start pH No low Yes pH high No Partly Compensated metabolic acidosis HCO3 Yes or low Compensated respiratory No alkalosis Mixed respiratory Yes PCO Yes HCO and high 2 low 3 metabolic acidosis No No Yes PCO Partly low 2 compensated metabolic No acidosis Uncompensated metabolic acidosis Partly compensated respiratory acidosis Yes HCO high 3 compensated HCO3 Yes respiratory low No alkalosis Yes HCO Yes high 3 No Uncompensated respiratory alkalosis high Mixed No Yes respiratory PCO2 and low metabolic alkalosis Normal No HCO3 Yes respiratory Compensated acidosis or Compensated metabolic alkalosis high No PCO2 Yes compensated metabolic alkalosis Partly No Uncompensated respiratory acidosis Uncompensated metabolic acidosis Figure 3–13 Flow chart illustrating a simplified acidbase interpretation scheme.0 3.(mEq/L) 60 50 40 35 30 25 20 15 10 9 8 7 6 5 4 3 HCO3 _ (kPa) PCO2 (mm Hg) 10 pH 8.5 7.0 8.7 6.9 6.8 6. and Pco2.0 4.
0 O 3L HC Eq/ 10 20 30 40 0 Metabolic Acidosis m 0 PCO2 (mm Hg) 50 60 70 80 90 100 1 2 3 4 5 6 (kPa) 7 8 9 10 11 12 13 Respiratory Acidosis 7. N = normal acidbase status.2 Partly Compensated Metabolic Acidosis Mixed Respiratory and Metabolic Acidosis 100 90 80 70 60 50 40 30 20 10 18 24 Partly Compensated Respiratory Acidosis pH 7.3 7.3 7.1 7.0 0 1 2 3 6 4 9 5 6 PCO2 (kPa) 7 8 9 10 11 12 13 18 21 24 100 90 80 70 60 50 40 30 20 10 12 15 7. .4 7.4 7. ARA = acute respiratory alkalosis.5 7.7 8. e 57 69 75 c oli tab sis Me cido A 42 48 (nM/L) H+ AR A Metabolic Alkalosis 0 Figure 3–14 An acidbase map for children and adults.1 7.0 Compensated N Metabolic CRA Acidosis Respiratory RA Alkalosis with Metabolic Acidosis Mixed Respiratory _ HCO3 and Metabolic Alkalosis RMA CMA Compensated Respiratory Acidosis (nM/L) H+ Metabolic Alkalosis Metabolic Alkalosis with Respiratory Acidosis 10 20 30 40 (mm Hg) PCO2 50 60 70 80 90 100 Figure 3–15 An acidbase map for neonates. CRA = compensated respiratory alkalosis. CRA = chronic respiratory alkalosis.7 8.2 pH 7. N = normal acidbase status.5 7.7. RMA = mixed respiratory and metabolic acidosis. PCO2 7.0 CRA N s ut c Re Ac Chroni cidosis A 27 is os 30 cid 33 .A sp 36 Re p. CMA = compensated metabolic alkalosis.6 7.6 7. RA = respiratory alkalosis.
In disease states characterized by elevated organic acids. the anion gap increases. The anion gap decreases 2.78  CHAPTER 3 Physiologic Monitoring 30 Carbamino CO2 in venous blood 25 Arterial point 20 Carbamino CO2 in arterial blood Mixed venous point 60 Blood carbon dioxide content (mmol/l) 50 CO2 content (ml/100 ml) 40 15 As bicarbonate ion in plasma and erythrocytes 30 10 20 5 10 as dissolved CO2 0 20 40 PCO2 (mm Hg) 60 0 80 Figure 3–16 Components of carbon dioxide curve for whole blood. Abbreviation: AG Units: mEq/L Normal value: 15–20 Equations: AG = (Na+ + K+) – (Cl– + HCO2 ) 3 . Anion Gap The anion gap is used to evaluate the nature of a metabolic acidosis.3 to 2.5 mEq/L for every 1 g/dL albumin reduction in plasma.
Abbreviation: D/D Units: mEq/L Normal value: 1–2 . the acid will react with HCO2 to produce water and CO2. Hence. and ketones 1:1.5 3 phosphate]) 2 lactate (normal range is 0) where adjAG = albuminadjusted anion gap AGc = anion gap corrected Na+ = serum sodium concentration (mEq/L) K+ = serum potassium concentration (mEq/L) Cl– = serum chloride concentration (mEq/L) HCO2 = serum bicarbonate concentration (mEq/L) 3 Albumin (g/dL) Phosphate (mg/dL) Lactate (md/dL) (normal range 8–12) Delta–Delta Gap A ratio used to evaluate mixed acid–base disorders.6/1.BloodGas Analysis: Traditional and the Stewart Method  79 or AG = Na+ – (Cl– + HCO2 ) 3 or adjAG = [(Na+ + K+) 2 (Cl– + HCO2 ) + (2.5 3 ([normal albumin] 2 3 [observed albumin])) or AGc = ([Na+ + K+] 2 [Cl– + HCO2 )] 2 ([2 3 albumin] + 3 [0. Note: The ratio depends on how the acid is buffered. one expects 3 that for every acid molecule produced. one bicarbonate molecule should decrease. It is based on the buffer concept that for every molecule of acid added to the extracellular fluid. Lactic acid ratio is 1.
9287 3 1HCO2 2 24.023 3 Hb2 or or SBE 5 0. the standard base excess (SBE) standardizes the effect of hemoglobin on CO2 titration. To enhance the behavior of the formula in vivo. Further corrections (corrected SBE) take into account albumin and phosphate yielding the closest behavior to actual physiology.80  CHAPTER 3 Physiologic Monitoring Equation: D> D 5 where AGmeasured 2 AGnormal HCO2 normal 2 HCO2 measured 3 3 AG = anion gap (mEq/L) HCO2 = serum bicarbonate concentration (mEq/L) 3 Base Excess The amount of acid or base that must be added to a sample of whole blood in vitro to restore the pH to 7.7g 3 fpH 2 7.4g2 3 SBEc 5 1HCO2 2 24.83 3 fpH 2 7.40 while the Paco2 is held at 40 mmHg.32g2 3 1pH 2 7.4 1 f2.2 Equations: 2 BE 5 1HCO3 2 24.4g2 3 11 2 0.3 3 albumin 3 0.3 3 Hb 1 7.4 1 f2.15g 3 1 f0.42 1 1f8.42 where BE = base excess (mEq/L) SBE = standard base excess (mEq/L) .3 3 Hb 1 14. It represents the quantity of metabolic acidosis or alkalosis. Abbreviation: BE. and SBEc Units: mEq/L Normal value: .29 3 phosphate 3 0. SBE.
Electrical charge equation 2 22 [SID1] = [HCO3 ] + [A2] + [CO3 ] + [OH2] 2 [H1] . [HA]. The dependent variables ([H1]. [OH2]. Carbonate ion formation equilibrium 2 [H1] 3 [CO322] = K3 3 [HCO3 ] 6. His view expressed that acid–base physiology has independent and dependent variables. Bicarbonate ion formation equilibrium 2 [H1] 3 [HCO3 ] = K9 3 S 3 Pco2 1 5. Thus. 22 [HCO2 ]. Conservation of mass for A [ATOT] = [HA] + [A2] 4. Weak acid dissociation equilibrium [H1] 3 [A2] = Kax [HA] 3. departing from the concept that HCO2 and pH are controlled directly. Water dissociation equilibrium [H1] 3 [OH2] = K9 w 2.BloodGas Analysis: Traditional and the Stewart Method  81 HCO2 = serum bicarbonate concentration (mEq/L) 3 Hb = hemoglobin (mmol/L) (1 mmol/L = 0. [A2]) are controlled by the independent variables 3 (Pco2. and 3 establishing the mathematical bases to explain the control by the independent variables. [CO3 ]. There are six equations that describe the interactions between dependent and independent variables: 1. Stewart introduced in 1981 an alternative view to the interpretation of acid–base theory.1 mg/dL Hb) pH = power of hydrogen (dimensionless) Albumin (g/dL) Phosphate (mg/dL) Stewart Approach to Acid–Base Disorders Peter A. total weak nonvolatile acids and the strong ion difference).
The apparent SID is directly calculated from available strong cations and anions in blood. calculations to obtain the apparent and the effective difference are available. serum proteins. In practice.where [A ] = dissociated weak acid concentration. principally albumin and phosphate a Na lactate HCO3 K A Mg Ca Cl other strong anions e . The effective SID (conceptually the same as the known buffer base) is calculated with the CO2. albumin. this is incalculable because we are unable to measure all strong ions. and albumin K 1 = apparent equilibrium constant for the Henderson–Hasselbach equation S = solubility of CO2 in plasma K3 = apparent equilibrium dissociation constant for bicarbonate SID = strong ion difference (see below) The difference in strong ions ([Na + K ] [Cl + lactate]). inorganic phosphate. and phosphate. Abbreviation: [SID ]a and [SID ]e Units: mEq/L Normal value: SID = 40 mEq Equations: SID SID where Mg = ionized magnesium concentration (mEq/L) Ca = ionized calcium (mEq/L) [A ] = concentration of dissociated weak noncarbonic acids. However. mostly albumin and phosphate [HA] = concentration of weak acid associated with a proton K w = autoionization constant for water Ka = weak acid dissociation constant for HA [Atot] = total concentration of weak nonvolatile acids.
et al. formate. and other plasma proteins. Change in [Atot] Changes in concentration of phosphate. The SIG may better represent the amount of unmeasured anions. Abbreviation: SIG Units: mEq/L Normal value: 0 Equation: SIG 5 fSID1 g a 2 fSID1g e Based on these concepts. Change in concentration i. when compared to the anion gap. or ketones (low [SID] and high SIG) 2. . Dehydration: Concentrates alkalinity and increases [SID] ii. Changes in strong ion concentrations i. Organic acids: Accumulation of lactate. the SIG may be high (a manifestation of unmeasured anions) while the anion gap is normal. Table 3–9 Classification of AcidBase Disorders Based on Stewart Independent Variables Respiratory Changes in Paco2 produce expected changes in [H+] Metabolic 1. Critical Care 9 (2005). acid–base disorders can be classified using the independent variables (Paco2 and Atot and SID).BloodGas Analysis: Traditional and the Stewart Method  83 Strong Ion Gap (SIG) The difference between the effective and apparent SID. H. albumin. H20 overload: Dilutes alkalinity and decreases [SID] b. 184–192. A particular example is when the albumin is low. E. Data from Corey. Inorganic acids: Increase in chloride (low [SID] and low SIG) ii. Change in [SID] a. See Table 3–9.
0 (adults). cardiac output may be increased by increasing either heart rate or stroke volume.0–8.0 (adult) Equation: # Q 5 # VO 2 1CaO2 2 CVO22 3 10 where # VO2 = (mL/min STPD) Cao2 = arterial oxygen content (mL/dL) CVO2 = mixed venous oxygen content (mL/dL) Cardiac Index Cardiac output varies with body size and has been shown to increase in proportion to the surface area of the body. All flowrelated hemodynamic variables can be indexed by substituting cardiac index for cardiac output in their equations. Cardiac Output (Fick Principle) This equation is valid if two blood samples (arterial and mixed venous blood) are drawn simultaneously during mixed expired gas collection and assume a steady state of ventilation and circulation. Increasing the heart rate is the most rapid method of increasing cardiac output. Thus. The cardiac index (cardiac output per square meter of BSA) is therefore useful in comparing the cardiac outputs of differentsized people. Abbreviation: CO Unit: L/min Normal value: 4. . cardiac output for all patients can be found by multiplying normal cardiac index by body surface area (BSA). # Abbreviation: Q Units: L/min Normal value: 4.0–8.84  CHAPTER 3 Physiologic Monitoring ■■ hEModynaMics Cardiac Output Cardiac output equals heart rate times stroke volume. which can double or triple in a healthy person.
5 (children and adults) Equation: CI = CO/BSA where CO = cardiac output (L/min) BSA = body surface area (m2) Stroke Volume The volume that the left ventricle ejects with each contraction.7–4. (2) ventricular enddiastolic volume (preload).Hemodynamics  85 Abbreviation: CI Units: L/min/m2 Normal value: 2. It is influenced by (1) cardiac contractility. Abbreviation: SV Units: mL/beat Normal value: 60–130 (adults) Equation: SV 5 where CO = cardiac output (L/min) HR = heart rate (bpm) CO 3 1000 HR Stroke Index Abbreviation: SI Units: mL/beat/m2 Normal value: 30–50 (children and adults) Equation: SI 5 CI 3 1000 HR . and (3) impedance to left ventricular outflow (afterload).
The mean arterial pressure is directly proportional to the cardiac output and the systemic vascular resistance. Any change in cardiac output (provided the resistance stays constant). either by stroke volume or heart rate. will cause a corresponding change in mean arterial pressure. Thus. it is this parameter that is important from the perspective of tissue blood flow. It represents the force that drives the blood through the systemic circulatory system.86  CHAPTER 3 Physiologic Monitoring where CI = cardiac index (L/min/m2) HR = heart rate (bpm) Mean Arterial Pressure The average blood pressure. Abbreviation: MAP Units: mm Hg Normal value: 82–102 (adults) Equations: MAP > 1/3(systolic 2 diastolic) + diastolic or MAP > or where 1systolic 1 2 3 diastolic2 3 CO = cardiac output (L/min) SVR = systemic vascular resistance CVP = central venous pressure MAP 5 1CO 3 SVR2 1 CVP Central Venous Pressure Abbreviation: CVP Units: mm Hg Normal value: 1–7 (adults) .
Vascular Resistance The opposition to blood flow in a vessel.Hemodynamics  87 Table 3–10 Hemodynamic Parameters Intracardiac Pressure Values Location Right atrium Mean Right ventricle Systolic Diastolic Pulmonary artery Systolic Diastolic Mean Pulmonary artery occlusion pressure Mean Left atrium Mean Left ventricle Systolic Diastolic * Pressure* (mm Hg) 22–6 14–38 0–7 12–28 4–12 6–18 6–12 6–12 81–141 3–11 Based on normal patients aged 2 months to 20 years. Resistance is defined as # R 5 DP>Q where R = resistance DP = the difference in pressure between two points in a vessel # Q = the flow of blood through a vessel . Vascular resistance cannot be measured directly but is calculated from measurements of blood flow and pressure.
The units of resistance in this system are dyne ? s/cm5 and may be calculated from pressure and flow measurements by the following formula: dyne ? s>cm5 5 where 1133321mm Hg2 mL>s 5 179. Systemic Vascular Resistance Abbreviation: SVR Normal value: 900–1600 dyne ? s>cm5 (adults) Equation: SVR 1units2 5 MAP 2 CVP CO where MAP = mean arterial pressure (mm Hg) CVP = central venous (or mean right atrial) pressure (mm Hg) CO = cardiac output (L/min) Systemic Vascular Resistance Index Abbreviation: SVRI Normal value: 1760–2600 dyne ? s>cm5>m2 (children and adults) 10–15 units/m2 (infants) 15–30 units/m2 (children and adolescents) Equation: SVRI 1units2 5 MPA 2 CVP CI . then R is said to be 1 resistance unit.88  CHAPTER 3 Physiologic Monitoring When DP = 1 mm Hg and flow is 1 mL/sec. Resistance may also be expressed as a basic physical unit in the centimetergramsecond (CGS) system of measurement.9221mm Hg2 L>min 1333 = the factor to convert mm Hg to dyne/cm2 To convert from “units” to dyne ? s>cm5. simply multiply the number of units by 79.92 (80 is not used in most texts).
2 units (adults) Equation: PVR 1units2 5 MPAP 2 PAOP CO where Pulmonary Vascular Resistance Index Abbreviation: PVRI Normal value: 45–225 dyne ? s>cm5>m2 (children and adults) 8–10 unit/m2 (newborn) 3 unit/m2 (infants) Equation: PVR 1units2 5 MPAP = mean pulmonary artery pressure (mm Hg) PAOP = pulmonary artery occlusion pressure or mean left atrial pressure (mm Hg) CO = cardiac output (L/min) MPAP 2 PAOP CI where MPAP = mean pulmonary artery pressure (mm Hg) PAOP = pulmonary artery occlussion pressure or mean left atrial pressure (mm Hg) CI = cardiac index (L/min/m2) . .160 dyne ? s>cm5 .Hemodynamics  89 where MAP = mean arterial pressure (mm Hg) CVP = central venous (or mean right atrial) pressure (mm Hg) CI = cardiac index (L/min/m2) Pulmonary Vascular Resistance Abbreviation: PVR Normal value: .
Coronary artery collapse occurs at approximately 40 mm Hg. Left Ventricular Stroke Work Index Abbreviation: LVSWI Units: g ? m>m2 Normal value: 42–64 (children and adults) .90  CHAPTER 3 Physiologic Monitoring Coronary Perfusion Pressure For mean aortic diastolic pressures between 40 and 80 mm Hg. Therefore. coronary artery perfusion pressure should be maintained at 60 to 80 mm Hg. coronary circulation is nearly a linear function of perfusion pressure at the coronary ostia. It is a parameter used in evaluating the pumping function of the heart. Equation: Coronary perfusion pressure = arterial diastolic pressure – LVEDP where LVEDP = left ventricular enddiastolic pressure (mm Hg) and LVEDP < pulmonary artery occlusion pressure Cerebral Perfusion Pressure Abbreviation: CPP Units: mm Hg Normal value: 70–110 Equation: CPP = MAP 2 ICP where MAP = mean arterial pressure (mm Hg) ICP = intracranial pressure (mm Hg) Stroke Work The product of the amount of blood ejected from a ventricle multiplied by the average pressure generated during that heartbeat.
0136 where SI = stroke index (mL/m2) MAP = mean arterial pressure (mm Hg) PAOP = pulmonary artery occlusion pressure (mm Hg) Left Cardiac Work Index Abbreviation: LCWI Units: kg ? m/m2/min Normal value: 2.0136 < SI 3 MAP 3 0.8–4.6 (children and adults) Equation: RVSWI = SI 3 (MPAP 2 CVP) 3 0.8–7.0136 < SI 3 MPAP 3 0.Hemodynamics  91 Equation: LVSWI = SI 3 (MAP 2 PAOP) 3 0.3 (children and adults) Equation: LCWI = CI 3 (MAP 2 PAOP) 3 0.0136 where SI = stroke index (mL/m2) MPAP = mean pulmonary artery pressure (mm Hg) CVP = central venous pressure (mm Hg) .0136 < CI 3 MAP 3 0.0136 where CI = cardiac index (L/min/m2) MAP = mean arterial pressure (mm Hg) PAOP = pulmonary artery occlusion pressure (mm Hg) Right Ventricular Stroke Work Index Abbreviation: RVSWI Units: g ? m/m2 Normal units: 3.
QO2 DO2I (indexed to BSA) Unit: mL/min/m2 (STPD) for DO2I.6 (children and adults) Equation: RCWI = CI 3 (MPAP 2 CVP) 3 0.. mL/min for DO2 Normal value: DO2 5 950–1150 mL/min DO2I 5 520–720 mL/min/m2 Equations: DO2 5 CaO2 3 CO 3 10 DO2I 5 CaO2 3 CI 3 10 where Cao2 = arterial oxygen content (mL/dL) CI = cardiac index (L/min/m2) CO = cardiac output (L/min) Note: Brain hypoxia is probable when O2AV drops below 450 mL/min/m2. # # Abbreviation: VO2 and VO2I (indexed to BSA) # # Units: mL/min/m2 (STPD) for VO2I.0136 < CI 3 MPAP 3 0. as in cyanide poisoning). See Tables 3–11 and 3–12. where CI = cardiac index (L/min/m2) MPAP = mean pulmonary artery pressure (mm Hg) CVP = central venous pressure (mm Hg) Oxygen Availability (Delivery) Oxygen availability (sometimes called oxygen delivery) is the total amount of oxygen potentially available for tissue consumption per unit time. Oxygen Consumption The amount of oxygen extracted from the blood by the tissues.4–0. DO2 .92  CHAPTER 3 Physiologic Monitoring Right Cardiac Work Index Abbreviation: RCWI Unit: kg ? m/m2/min Normal value: 0.0136.g. # Abbreviation: O2AV. Oxygen consumption may be limited by the oxygen availability or by tissue extraction (e. mL/min for VO2 # Normal value: VO2I 5100–180 (children and adults) # VO2 5 200–250 .
49 3 ln (age) + 0.04 3 ln (age) + 0.1 2 17.1 2 11.378 3 (heart rate) Females: # VO2 = 138.Hemodynamics  93 Table 3–11 Oxygen Consumption (mL/min/m2) as a Function of Age and Heart Rate for Males Heart Rate (bpm) Age (yr) 50 60 70 80 90 100 110 120 130 140 150 3 156 159 163 167 171 175 178 182 4 149 152 156 160 164 168 171 175 179 6 140 144 148 152 155 159 163 167 170 174 8 137 141 144 148 152 156 160 163 167 171 10 131 134 138 142 146 149 153 157 161 165 168 12 128 132 136 140 144 147 151 155 159 162 166 14 127 130 134 138 142 14 149 153 157 161 164 16 125 129 133 136 140 144 148 152 155 159 163 18 124 128 131 135 139 143 146 150 154 158 162 20 123 126 130 134 138 141 145 149 153 157 160 25 120 124 128 131 135 139 143 146 150 154 158 30 118 122 125 129 133 137 141 144 148 152 156 35 116 120 124 127 131 135 139 143 146 150 40 115 118 122 126 130 134 137 141 145 149 Equations: # VO2 5 1CaO2 2 CVO22 3 CO4 3 10 # VO2 5 1CaO2 2 CVO22 3 CI 3 10 where Cao2 = arterial oxygen content (mL/dL) CVO2 = mixed venous oxygen content (mL/dL) Prediction Equations: Males: # VO2 = 138.378 3 (heart rate) .
Conversely. given a stable level of hemoglobin. loge) Oxygen Extraction Ratio A ratio of the oxygen consumption to the oxygen availability and an indicator of the body’s metabolic level (for a given cardiac output).94  CHAPTER 3 Physiologic Monitoring Table 3–12 Oxygen Consumption (mL/min/m2) as a Function of Age and Heart Rate for Females Heart Rate (bpm) Age (yr) 50 60 70 80 90 100 110 120 130 140 150 150 153 157 161 165 169 172 176 141 145 148 152 156 160 164 167 171 130 134 138 142 145 149 153 157 160 164 125 129 133 137 140 144 148 152 156 159 10 118 122 125 129 133 137 140 144 148 152 156 12 115 118 122 126 130 134 137 141 145 149 152 14 112 116 120 123 127 131 135 138 142 146 150 16 110 114 117 121 125 129 132 136 140 144 148 18 108 112 115 119 123 127 130 134 138 142 146 20 106 110 114 117 121 125 129 132 136 140 144 25 102 106 110 113 117 121 125 129 132 136 140 30 99 103 107 110 114 118 122 126 129 133 137 35 96 100 104 108 112 115 119 123 127 130 40 94 98 102 105 109 113 117 121 124 128 where heart rate is in beats per minute ln represents the natural logarithm (i. Abbreviation: O2ER Units: % Normal value: 22–30 (children and adults) . an increasing oxygen extraction ratio indicated a fall in cardiac output. and oxygen consumption.e.. arterial saturation.
Hemodynamics  95 Equation: O2ER 5 where 1CaO2 2 CVO22 CaO2 Cao2 = arterial oxygen content (mL/dL) CVO2 = mixed venous oxygen content (mL/dL) Oxygen Extraction Index Abbreviation: O2EI Units: % Normal value: 22–25% Equation: O2EI 5 where 1SaO2 2 SVO22 SaO2 SaO2 = Oxygen saturation of arteral blood SVO2 = Oxygen saturation of mixed venous blood .
.
CHAPTER Gas Therapy 4 .
e. If a gas is saturated with water vapor. where k is a constant. pressure. the preceding equation is applied to the dry gas portion of the mixture. . at a given temperature its dry gas pressure is obtained by subtracting the water vapor at that temperature.98  CHAPTER 4 Gas Therapy For the respiratory care practitioner to provide gas therapy effectively. the general gas law is most often utilized to correct for the volume change when pressure and temperature are changed. This chapter will describe the relationships among pressure. We would use the combined gas law form: P1V1 P2V2 5 T1 T2 A common and useful application of the combined general gas law is converting gas volumes from room temperature (ATPS) to body conditions (BTPS). mass.0821 L ? atm/mole ? K) T 5 absolute temperature in degrees Kelvin (K) Since water vapor in a saturated mixture does not act like an ideal gas. temperature. and conversion equations that permit the practitioner to use these gases effectively. Furthermore. This chapter will also describe the packaging. it is necessary to understand the physics of gases. the general gas law is often simplified to PV/T 5 k. The equation relating these variables is called the ideal gas law and is written as PV 5 nRT where P 5 absolute pressure of dry gas in atmospheres (atm) V 5 volume in liters (L) n 5 moles of gas R 5 the universal gas constant: (0.. number of moles) remains constant. ■■ The General Gas law The behavior of an ideal gas is governed by the interdependent relationships of four thermodynamic variables: mass. In situations where mass (i. and absolute temperature. volume. and volume for most medical gases. distribution.
2 mm Hg V1 5 4.8 3 310 298 3 713 P1 V 1 T 2 T 1 P2 5 5.8 1at 258C2 5 736. the volume of a gas varies inversely with the pressure applied to that gas.2 L ■■ special Gas laws Boyle’s Law If temperature and mass remain constant. Symbolically.Special Gas Laws  99 Problem: Correct a measured vital capacity of 4. Solution: Condition 1 5 ATPS P1 5 PB 2 PH2O 5 760 2 23.8 L to BTPS given that the patient’s body temperature is normal and the pulmonary function laboratory is at sea level with a room temperature of 258C.8 L Condition 2 5 BTPS T1 5 258C 1 273 5 298 K P2 5 760 2 47 1at 378C2 5 713 mm Hg V2 5 unknown value T2 5 378C 1 273 5 310 K We derive the formula for converting gas volume from ATPS to BTPS by solving the combined gas law for V2.2 3 4. P1 V 1 P2 V 2 5 T1 T2 V2 5 and substituting the known values: V2 5 732. V5 k P .
. P1V1 5 P2V2 where k is a constant Problem: Consider a syringe filled with a certain amount of dry gas. a pneumothorax).36 5 182 cm H2O Another example of Boyle’s law is the effect of altitude changes on the volume of trapped gas (e. If the gauge pressure of the gas is 30 cm H2O when the volume of the gas is 40 mL.g. If the outlet is blocked while the plunger is depressed. what will the pressure be when the gas is compressed to 35 mL? Solution: Condition 1: P1 (absolute) 5 gauge pressure + atmospheric pressure 30 cm H2O 5 22 mm Hg P1 5 22 + 760 5 782 mm Hg V1 5 40 mL Condition 2: P2 5 unknown value V2 5 35 mL Solving Boyle’s law for the unknown variable gives P1V1 5 P2V2 P1 V 1 P2 5 V2 40 5 782 3 35 5 894 mm Hg P2 (gauge) 5 (894 2 760) 3 1.100  CHAPTER 4 Gas Therapy or. . as shown in Table 4–1. equivalently. the pressure of the gas inside the syringe will rise as its volume decreases (we assume that there are no leaks and that the temperature change of the gas is negligible).
The equations are V 5 kT or.058 400% 38.000 5.000 10.735 500% Charles’s Law If pressure and mass remain constant.500 11.486 200% 27.000 3. equivalently. we obtain .Special Gas Laws  101 Table 4–1 The Effect of Altitude on Trapped Gas Altitude (ft) (m) Expansion 10. what would its new volume be? Solution: Condition 1: V1 5 6. V1 V2 5 T1 T2 where k is a constant Problem: Suppose a certain quantity of helium occupies a volume of 6. the volume of a gas varies directly with the temperature of that gas.0 L at a room temperature of 228C.0 L T1 5 228C + 273 5 295 K Condition 2: V2 5 unknown value T2 5 378C + 273 5 310 K Solving the above equation for the unknown quantity.230 300% 33. If the same mass of helium were heated to 378C.000 8.048 150% 18.
what is its pressure at 2108C? Solution: Condition 1: P1 (absolute) 5 gauge pressure + atmospheric pressure P1 5 2200 psi + 14. Thus. we solve for the unknown pressure: .7 < 2215 psi T1 5 228C + 273 5 295 K Condition 2: P2 5 unknown value T1 5 2108C + 273 5 263 K Using the preceding equation. P 5 kT or P1 P2 5 T1 T2 where k is a constant Problem: A common example occurs at those institutions in the northern latitude that store their gas cylinders outside. the pressure of a gas varies directly with the temperature of that gas. If an H cylinder of oxygen was filled to 2200 psi at room temperature (228C).0 3 5 6.102  CHAPTER 4 Gas Therapy V1 V2 5 T1 T2 V2 5 Substituting the known quantities gives V2 5 6.3 L 310 295 V 1T 2 T1 GayLussac’s Law If volume and mass remain constant.
. Furthermore. For example. n1 n2 5 V1 V2 where k is a constant n is the number of moles of the gas From these equations it follows that equal volumes of gases at the same pressure and temperature have the same number of moles. the atomic weight of the molecule expressed in grams) occupies 22. the mass of a gas varies directly with the volume of that gas: n 5 kV or. the density of oxygen (ro2) is its gram molecular weight (gmw) divided by 22.4 L at STPD and contains 6. one gram molecular weight of a gas (i.e. equivalently.. Avogadro’s law provides the basis for the derivation of the density (mass per unit volume) of a gas.Special Gas Laws  103 P1 P2 5 T1 T2 P2 5 P1 T 2 T1 Substituting the known values gives P2 5 2215 3 263/295 5 1975 psi P2 (gauge) 5 1975 2 15 5 1960 psi/gauge pressure Avogadro’s Law If pressure and temperature remain constant.43 g/L at STPD.02 × 1023 molecules.4 L: 1 gmw O2 5 16 × 2 × 1 g 5 32 g ro2 5 32/22.4 5 1.
104  CHAPTER 4 Gas Therapy Specific gravity is a ratio of densities. Usually, gas densities are compared to air ( rair 5 1.28 g/L at STPD). Calculation of specific gravity for oxygen reveals that it is heavier than air: specific gravity of O2 5 1.43 g>L 1.28 g>L
or 5 1.12 It is this property of oxygen that causes the “layering” of oxygen in tents, making the Fio2 at the bottom of the canopy higher than at the top.
Dalton’s Law of Partial Pressures
The total pressure of a gas mixture is equal to the sum of the partial pressures of the constituent gases. The partial pressure of each gas is the pressure it would exert if it occupied the entire volume alone: Ptotal 5 P1 + P2 + P3 + . . . + Pn The partial pressure of each gas is proportional to its molar concentration in the mixture: Pg 5 Fg 3 Ptotal where Pg is the partial pressure of the gas Fg is the fractional concentration of the gas in the mixture Dalton’s law is important because it allows us to calculate the partial pressures of various inhaled gases. The physiologic effects of each component of inhaled air depend on the partial pressure of the component in the lungs rather than on the total pressure. As a rough approximation, the partial pressure (in kPa) is close to the concentration (in %) at normal barometric pressure. Partial pressure in mm Hg can be approximated by multiplying the concentration (in %) by 7. For example, the Po2 of air is approximately 21 3 7 5 147 mm Hg.
Poiseuille’s Law
Poiseuille’s law describes the mechanics of laminar fluid flow through a tube. # Ppr4 V5 8hl
Special Gas Laws  105 where # V 5 flow in cm3/s P 5 pressure difference across the ends of the tube (dyne/cm2) p 5 3.1416 . . . r 5 radius of tube (cm) l 5 length of tube (cm) h 5 viscosity in poise (dyne ? s/cm2) The preceding equation indicates that the pressure difference is directly proportional to the gas flow rate. Thus, for any flow rate, the pressure difference divided by the flow rate equals a constant. This constant is called resistance (R) and is defined as R5 8hl pr4 P 5 # V
The clinical significance of this definition centers around the importance of tube radius. For instance, if the radius of an airway is halved, the airway resistance in that section increases 16fold. Bronchospasm and mucous obstruction are two frequently encountered clinical conditions that reduce airway caliber (increasing airway resistance), resulting in a rise in proximal airway pressure during volume control ventilation or acute hypoventilation during pressure control ventilation. Another important point about this definition is that the only property of the gas that influences resistance during laminar flow is viscosity. This is in contrast to turbulent flow in which resistance is proportional to gas density. Therefore, under conditions of laminar flow, the clinical use of a lowdensity, highviscosity gas (e.g., helium) will do nothing to improve gas flow. However, if excessive airway resistance is caused by turbulence (as in croup or other forms of airway obstruction), density, not viscosity, becomes important.
Reynold’s Number
The factors that determine whether flow in a tube will be laminar or turbulent are related in the equation that defines a dimensionless quantity called the Reynold’s number: NR 5 rv2 r2rv inertial force 5 5 h viscous force h1v>2r2
106  CHAPTER 4 Gas Therapy where v 5 average linear velocity of the gas (cm/s) r 5 radius of tube (cm) r 5 density of gas (g/cm3) h 5 viscosity in poise (dyne ? s/cm2) In straight, smooth tubes, turbulence for most fluids is probable when the Reynold’s number exceeds 2000. Once flow becomes turbulent, the pressure difference required to produce a given gas flow rate through a given passage is proportional to gas density and the square of the gas flow rate but is independent of viscosity.
Bernoulli Theorem
For an incompressible fluid in laminar flow (assuming that there are no energy losses from friction), Bernoulli’s equation states that the energy densities at any two points in the system are equal: PE1 5 P1 + KE1 5 PE2 + P2 + KE2 where PE 5 potential energy per unit volume or height 3 density 3 gravitational acceleration P 5 pressure of the gas measured perpendicular to flow KE 5 kinetic energy per unit volume or 1/2 density 3 velocity squared Consider a fluid that flows from a relatively wide section of tubing (subscript 1 in the above equation) to a relatively narrow section (subscript 2). Since the crosssectional area in the narrow section is smaller, the velocity of the fluid must increase to keep the flow rate the same. As a result, the kinetic energy density (KE2) increases. Assuming that the potential energy density stays the same, the pressure (P2) at this point must decrease so that the right side of the equation remains equal to the left. Stated simply, as the forward velocity of the fluid increases, its radial pressure decreases. This is often called the Bernoulli effect.
Henry’s Law (Law of Solubility)
When a liquid and gas are in equilibrium, the amount of gas in solution is directly proportional to the partial pressure of the gas if temperature is
Special Gas Laws  107 constant. Expressed mathematically this is C 5 0.132aP where C 5 gas concentration in vol% (mL gas/dL liquid) a 5 the Bunsen solubility coefficient of the gas (mL gas STPD/mL solvent) (see Table 4–2) P 5 gas partial pressure (mm Hg) 0.132 5 a constant equal to 100/760 used to express C in vol%
Table 4–2 Bunsen Solubility Coefficients (mL STPD/mL Solvent)* Gas Plasma Blood** He 0.0154 0.0149 0.0117 0.0130 N2 0.0209 0.0240 O2 0.5100 0.4700 CO2
* **
Gas partial pressure 5 760 mm Hg and temperature 5 378C. Hematocrit 5 0.45.
Graham’s Law (Law of Diffusion)
Graham’s law states that the diffusion of a gas is inversely proportional to the square root of its molecular weight. For example, in comparing the relative rates of diffusion of carbon dioxide and oxygen, we get
where
2gmw O2 DCO2 232 5.6 5 5 5 DO 2 6.6 2gmw CO2 244
Dco2 5 diffusion coefficient for carbon dioxide Do2 5 diffusion coefficient for oxygen gmw 5 gram molecular weight From this we see that carbon dioxide diffuses only 0.85 times as fast as oxygen in the gaseous state owing to carbon dioxide’s greater molecular weight.
108  CHAPTER 4 Gas Therapy
Fick’s Law of Diffusion
The factors controlling the rate of diffusion of a gas into or out of a liquid are expressed in the equation
where # VGAS 5 diffused gas flow DP 5 pressure gradient across the gas–liquid interface A 5 crosssectional area S 5 solubility of gas d 5 distance for diffusion gmw 5 gram molecular weight of the gas In comparing the rates of diffusion of carbon dioxide and oxygen through an aqueous medium, it should be noted that for the same concentration gradient, carbon dioxide diffuses more slowly than oxygen. However, because of its 25 times greater solubility, carbon dioxide diffuses 20 times faster than oxygen for the same tension gradient.
# DP 3 A 3 S VGAS r 5 d 3 2gmw
Law of Laplace (for a Sphere)
The pressure difference between the inside and outside of a sphere is dependent on the surface tension of the air–liquid interface and the radius of the bubble. For a sphere with one air–liquid interface (e.g., an alveolus or a gas bubble in a liquid), the equation is Ptrans 5 where Ptrans 5 transmural pressure differences (dyne/cm2) T 5 surface tension (dyne/cm) r 5 radius of sphere (cm) For a sphere with two air–liquid interfaces (e.g., a sphere of gas enclosed in a thin film of liquid such as a soap bubble), the equation becomes PTRANS 5 4T r 2T r
This causes the surface tension to decrease to a greater extent than the corresponding reduction of radius so that the pressure (5 2T/r) decreases. the higher its transmural pressure difference. Absolute Humidity Absolute humidity is the water vapor density expressed in grams per cubic meter (or milligrams per liter) of air. This tendency is counteracted by the presence of surfactant on the inner surface of the alveolus. it is relative humidity 1%2 5 relative humidity 1%2 5 absolute humidity 3 100 capacity measured water vapor pressure 3 100 saturated water vapor pressure . it would seem that a small alveolus would have the natural tendency to empty its gas into a larger one and collapse. Mathematically. small alveoli in communication with large alveoli are able to equilibrate to the same pressure without collapsing. t t 5 temperature (8C) 287. the amount of surfactant per unit of surface area increases.7 3 RH 3 PSAT t 1 273 Relative Humidity The ratio of the actual amount of water vapor in a gas (absolute humidity) at a given temperature to the amount of water vapor the gas could hold if saturated at that temperature (capacity) is the relative humidity. the Laplace equation indicates that the smaller the radius of the sphere. It can be estimated using the following equation (derived from the ideal gas equation): AH 5 where AH 5 absolute humidity (mg/L or g/m3) RH 5 relative humidity expressed as a decimal Psat 5 the partial pressure of saturated water vapor (mm Hg) at the given temperature. Surfactant decreases the surface tension inside the alveolus in proportion to the ratio of surfactant to alveolar surface area. As an alveolus becomes smaller.Special Gas Laws  109 In either case. Thus. Thus.
90298) * (373.16/t)) 2 (1. The symbol + stands for multiplication.334 * (1 2 t/373.16/t 2 1)) + (5. Table 4–3 gives the values of K for various units of pressure..25 kilopascals (kPa) 101.3 Antoine Equation The saturated vapor pressure of water and a variety of anesthetic gases can be estimated using the Antoine equation: PSAT 5 antilogaA 2 where B b t 1 C Psat 5 units of pressure desired antilog 5 the antilogarithm (base 10) of the expression in parentheses . and K is a constant determined by the desired units for Psat. Hg) 29.02808 * LOG(373. 10ˆ2 5 100).e.26 centimeters of water (cm H2O) millibars (mb) 1013.16/t 2 1)) 2 1)))) where t is the temperature of the gas in degrees kelvin. Table 4–3 Goff–Gratch Equation Constants for Various Units of Pressure Desired Unit K atmosphere (atm) 1 14. and ˆ represents exponentiation (i.49149 * (373.2 (psi) inches of mercury (in. / stands for division.3816 * 10ˆ(27) * (10ˆ(11. LOG is logarithm (base 10).9213 millimeters of mercury (mm Hg) 760 1033.110  CHAPTER 4 Gas Therapy Goff–Gratch Equation Saturated water vapor pressure can be estimated from the temperature of the gas using the following adaptation of the Goff–Gratch equation (in computer or calculator notation): Psat 5 K * (10ˆ(((–7.696 pounds/in.132 * 10ˆ(23) * (10ˆ(23.16)) 2 1)) + (8.
36 55 28 28.69778 Enflurane 6. and Percent Saturation Temperature Vapor Pressure Water Content % Saturation at (8C) (mm Hg) (mg/L) 378C 20 17.38 21.82163 536.30 39 22 19.839 6.90 37. Table 4–4 gives values of A.063 Temperature Range of Data (8C) 25–135 240–36 251–55 25–49 17–56 Maximum Deviation from Data 1% 1% 3% 1% 0.35 27. t 5 temperature (8C) Table 4–4 Antoine Equation Data Substance A B (kPA) (mm Hg) Water 7. B.Special Gas Laws  111 A.57799 Halothane 5. B.262 140.697 6.21 24.04343 Nitrous 6. Table 4–5 Water Vapor Pressure. content.70184 912.78 50 26 25. and C for water and varieties of anesthetic gases.98840 C 232. commonly encountered in health care. and C 5 constants whose values depend on the chemical composition of the vapor.8988 oxide 7.82 30.66 33.22 62 30 31.984 8. and saturation for temperatures.4589 5.54 17.35 69 32 35.42 44 24 22.88 19.991 213.76 77 34 39.56 86 (continued) .538 285.76799 Isoflurane 4.11225 1107. Content.16728 1716.309 218.89184 1043.3% Table 4–5 gives values for water vapor pressure.
90 100 38 49.32 51.112  CHAPTER 4 Gas Therapy Table 4–5 Water Vapor Pressure.56 41. . Content.07 43.19 — 40 55.10 — 42 61. and Percent Saturation (continued) Temperature Vapor Pressure Water Content % Saturation at (8C) (mm Hg) (mg/L) 378C 36 44.50 — kPa mm Hg 8 60 55 7 6 Water Vapor Pressure 5 4 3 2 1 0 50 45 40 35 30 25 20 15 10 5 0 0 5 10 15 20 25 30 20 40 80 % Saturation 100 mg/L 50 40 Water Vapor Content 30 60 20 10 35 40 0 Temperature (°C) Figure 4–1 Water vapor pressure and content as a function of temperature (from the Antoine equation).69 46.50 56.70 95 37 47.
21 These equations were derived from the general equations (Fo2)(total flow) 5 (Fao2)(flow A) + (Fbo2)(flow B) and total flow 5 flow A + flow B where Fo2 5 final fraction of oxygen in mixture FxO2 5 fractional concentration of oxygen in the individual flows making up the mixture This equation simply states that the total flow of oxygen in the mixture is equal to the sum of the flows of oxygen in the gases being blended together. FIO2 5 O2 flow 1 10.79 FIO2 2 0. and fraction of inspired oxygen (Fio2) when blenders or entrainment systems are used.0 2 FIO2 airflow 5 O2 flow FIO2 2 0.21 total flow 3 1FIO2 2 0.21 3 airflow2 10. airflow.Oxygen Administration  113 ■■ OxyGen adminisTraTiOn Blender or Entrainment System Equations The following equations relate the variables of oxygen.79 3 O2 flow2 total flow total flow 0.21 1 O2 flow 5 airflow 5 total flow 2 O2 flow total flow 5 O2 flow 3 0. total flow. . flow.79 5 0.212 1.
concentrator flow rate (VC).21 0.21 FIO2 0.21 If the FCo2 drifts from its expected value due to concentrator malfunction.21 0.21 0.21 act FCO2 0.21 Fio2 volume of inspired O2 ÷ tidal volume (Vt) . However.21 0.21 0.21 FIO2 FCO2 0. as these devices usually do not provide control of Fio2.In the home care environment. In this case. the preceding equations apply. it may be convenient to use an oxygen concentrator. the total flow of gas from the ventilator and the concentrator). If pure oxygen is used. the fractional concentration of oxygen delivered by the concentrator (FCo2) must be known. and the flow of gas from the ventilator (VAIR equal to the product of tidal volume and ventilator frequency) may be expressed as follows.21 0. FIO2 VE VAIR VAIR VC VC FCO2 FCO2 FIO2 FCO2 FIO2 VE FIO2 FCO2 VAIR VE VC VC VE VE 0. the resultant effect on Fio2 may be estimated using the equation: act FIO2 where act actual expt expected expt FIO2 expt FCO2 0. it is often necessary to blend oxygen into the gas delivered by a home care ventilator. The relationships among Fio2 total minute ventilation (VE .21 0.
volume of inspired O2 5 50 mL + 100 mL + 70 mL 5 220 mL and Fio2 5 220 mL 4 500 mL 5 0.20 3 (Vt 2 Vd) 5 0.Oxygen Administration  115 volume of inspired O2 5 (a) volume of O2 inspired from anatomic reservoir plus (b) volume of O2 delivered by cannula during inspiration plus (c) volume of O2 from inspired room air Example normal Vt 5 500 mL frequency 5 20 breath/min inspiratory time 5 1 s expiratory time 5 2 s period of no expiratory flow 5 25% of expiratory time 5 0.20 3 (500 2 150) 5 70 mL Therefore.0 s 5 100 mL (c) volume of O2 from inspired room air 5 0.5 s anatomic reservoir 5 50 mL < 30% of anatomic dead space nasal cannula flow rate 5 6 L/min (100 mL/s) Thus. (a) volume of O2 inspired from anatomic reservoir 5 100 mL/s 3 0.44 .5 s 5 50 mL (b) volume of O2 delivered by cannula during inspiration 5 100 mL/s 3 1.
9th Edition. Louis: Mosby Elsevier.24 0. Egan’s Fundamentals of Respiratory Care. R.50 0. J..32 0. 25 30 10 9 8 7 Air (L/min) 6 5 4 3 2 1 0 2 1 35 40 45 FIO2 (%) 50 55 18 16 14 60 65 12 Total Flow 10 8 6 4 70 75 80 85 90 95 2 3 4 5 6 7 Oxygen (L/min) 8 9 10 Figure 4–2 Inspired oxygen concentration as a function of mixed air and oxygen flow rates (low range of flow). Data from Wilkins.44 0. L. K. Kacmarek.40 0. R. Stoller. St.. M. 2009:874.28 0.116  CHAPTER 4 Gas Therapy Table 4–6 LowFlow Oxygen Systems* System O2 Flow Rate (L/min) Nasal cannula or catheter 1 2 3 4 5 6 Simple oxygen mask 5–10 Mask with reservoir bag 8–10 * Approximate Fio2 0. .35–0.80 Normal tidal volume and respiratory rate are assumed.36 0.60–0.
Gas Cylinders  117 FIO2 (%) 25 30 50 45 40 35 Air (L/min) 30 25 20 15 10 5 0 10 5 35 40 45 50 55 90 80 70 60 65 60 Total Flow 50 40 30 20 70 75 80 85 90 95 10 15 20 25 30 35 Oxygen (L/min) 40 45 50 Figure 4–3 Inspired oxygen concentration as a function of mixed air and oxygen flow rates (high range of flow).3 1L>ft32 3 volume of gas in full cylinder 1ft32 pressure of full cylinder 1psi2 where 28. ■■ Gas cylinders Duration of Cylinders The first step in calculating the duration of flow from a cylinder of compressed gas is to relate the decrease in cylinder volume to the drop in the cylinder’s gauge pressure. is calculated as follows: K 1L>psi2 5 28. relating gas volume to pressure drop. . The factor K.3 5 the factor to convert cubic feet to liters Table 4–7 gives values for the K factors for different gases and cylinder sizes.
if a 70%–30% helium–oxygen mixture is used with an oxygen flowmeter. Therefore. The calibration factor of a flowmeter is inversely proportional to the square root of the molecular weight of the gas. Thus.8 . tasteless. duration of flow 1min2 5 K 3 gauge pressure 1psi2 Helium Therapy Helium is odorless.. the duration of constant flow can be calculated from the gauge pressure using the equation: flow rate 1L>min2 Table 4–8 gives approximate number of hours of flow according to cylinder size.6 desired flow rate 1. Because the calibration of standard flowmeters (i. helium has been used in the management of airway obstruction where turbulent gas flow patterns cause an increase in airway resistance and increase the work of breathing. Commercially prepared cylinders of helium–oxygen mixtures are available in 80%–20% and 70%–30% combinations. and physiologically inert. Because of its low density. the following equations are used. nonexplosive. 80%–20% helium–oxygen mixture: required flowmeter setting 5 70%–30% helium–oxygen mixture: required flowmeter setting 5 desired flow rate 1.e. to obtain a desired flow rate of a given mixture with an oxygen flowmeter. Thorpe tube) depends on gas properties.118  CHAPTER 4 Gas Therapy Once the value of K is found for a particular size of cylinder. the measured flow must be multiplied by 2gmw O2> 2gmw mixture to obtain the actual flow rate. a correction must be applied when helium–oxygen mixtures are used with flowmeters calibrated for oxygen or air.
CO2.28 2.3 3.6 7.5 Table 4–9 Medical Gas Cylinder Color Codes* Gas Symbol United States Carbon dioxide Gray CO2 Cyclopropane Orange C3H6 Ethylene Red C2H6 Helium He Brown Nitrous oxide Blue N2O Oxygen Green O2 Oxygen–carbon dioxide Gray + green Oxygenhelium Brown + green Air Yellow + silver * H and K 3.5 12 0.7 0.6 7 10 1.35 2. air 0.50 1/4 Full E H 1.2 0.2 14 0.14 3.5 0.4 5.1 1.84 2.8 9.5 15 0.9 9.7 0.2 0.3 13.2 8 1. 28 1.16 0.1 56 3.5 0.3 3.5 0.2 0.94 He/O2 0.5 1.7 International Gray Orange Violet Brown Blue White Gray + white Brown + white White + black Note: Color codes are accurate for E cylinders only. .41 O2/CO2 0.14 0.5 5.3 14 0.6 6. N2.5 0.93 Table 4–8 Approximate Number of Hours of Flow Cylinder Type Flow Rate Full 3/4 Full 1/2 Full (L/min) E H E H E H 2 5.2 2.4 4.2 0.8 21 1.Gas Cylinders  119 Gas Therapy Working Tables and Figures Table 4–7 K Factors (L/psi) to Calculate Duration of Cylinder Flow Cylinder Size Gas D E G O2.7 18.5 28 4 2.23 1.8 42 2.20 0.7 8.6 7 0.2 14 6 1.7 0.4 4.0 11 0.9 10.2 2.
5 5.5 8.5 11.) (cm) (in.5 21.6 55 139.7 Table 4–11 Medical Gas Cylinder Specifications Gas Oxygen Carbon dioxide Helium Nitrous oxide Cyclopropane Ethylene Oxygen–carbon dioxide mix Oxygen–helium mix Pressure (psi) 1800–2400 840 1650–2000 745 80 1250 1500–2200 1650–2000 ft L ft3 L ft3 L ft3 L ft3 L ft3 L ft3 L ft3 L 3 Weight (lb) 2.6 752 12.800 44 1245 22 622 18 510 372 10.8 47 119.5 975 30 848 26.9 55 139.6 356 33 934 10.25 15 66 98 100 (kg) 5.7 H&K 9 22.25 10.6 22.6 300 34.120  CHAPTER 4 Gas Therapy Table 4–10 Medical Gas Cylinder Dimensions Diameter Height Size (in.4 G 8.) (cm) A 3 7.5 11.4 30 76.25 10.2 M 7 17.9 16 40.8 20 50.6 220 D 12.2 215.8 E 4.750 H & K 244 6900 577 15.6 10 25.4 B 3.500 186 5620 150 4250 .6 356 11 310 Cylinder Size E G 22 186 622 5260 56 425 1585 12.000 17 146 480 4130 57 485 1610 13.6 D 4.6 33 145.
965”14NGORHINT. 320 those shown above) (flat nipple) .Gas Cylinders  121 Table 4–12 Pin Index and CGA Standards Gas Oxygen Carbon dioxide–oxygen (CO2 not over 7%) Helium–oxygen (He not over 80%) Ethylene Nitrous oxide Cyclopropane Helium Helium–oxygen (He not over 80%) Carbon dioxide Carbon dioxide–oxygen (CO2 over 7%) (mixtures other than those shown above. No. Table 4–13 New Standard Threaded Valve Outlet Connections for Medical Gases Gas Outlet Thread CGA Connection Oxygen 0. 280 Helium Helium–oxygen (He over 80%) 0. 540 Carbon dioxide Carbon dioxide–oxygen (CO2 over 7%) 0.825”14NGORHEXT.825”14NGOLHEXT. for lab use only) * Pin Position 2–5 2–6 2–4 1–3 3–5 3–6 4–6 1–6 No CGA standard CGA Con.885”14NGOLHINT.903”14NGORHEXT.* 870 880 890 900 910 920 930 940 CGA Con. 5 Compressed Gas Association connection.825”14NGORHEXT. 1320 (small round nipple) Ethylene 0. 350 (round nipple) Cyclopropane 0.745”14NGORHEXT. 320 (flat nipple) Carbon dioxide–oxygen (CO2 not over 7%) Helium–oxygen (He not over 80%) 0. 510 Special mixtures (mixtures other than 0. 580 Nitrous oxide 0.825”14NGORHEXT.
(See Table 4–12.) Body Nipple and hex nut Bore 1 Bore 2 Shoulder 1 Shoulder 2 Figure 4–5 Schematic illustration of components of a representative diameter index safety system (DISS) connection. . CGA standard.122  CHAPTER 4 Gas Therapy 1 2 3 6 5 4 Figure 4–4 Pplt index. The two shoulders of the nipple allow the nipple to unite only with a body having corresponding borings.
. saturated with water vapor) BTPS ATPD STPD ATPD (ambient temperature and pressure. dry) BTPS ATPS STPD BTPS (body temperature and ambient pressure. and the saturating pressure of water (Ph2o) in mm Hg at ambient temperature. dry) ATPS ATPD Multiply By PB 2 PH 2 O 273 3 760 273 1 T PB 2 PH 2 O 310 3 PB 2 47 273 1 T PB 2 PH 2 O PB PB 273 3 760 273 1 T 310 PB 3 PB 2 47 273 1 T PB PB 2 PH 2 O PB 2 47 273 3 760 310 PB 2 47 273 1 T 3 PB 2 PH 2 O 310 PB 2 47 273 1 T 3 PB 310 760 310 3 PB 2 47 273 760 273 1 T 3 PB 2 PH 2 O 273 760 273 1 T 3 PB 273 *Based on ambient temperature (T) in 8C. saturated with water vapor at body temperature) ATPS ATPD BTPS STPD (standard temperature and pressure. barometric pressure (Pb) in mm Hg.Gas Cylinders  123 Table 4–14 Gas Volume Correction Equations* To Convert From To STPD ATPS (ambient temperature and pressure.
000 *Volume (BTPS) 5 volume (ATPS) 3 conversion factor.057 29 1.085 24 1.. Small deviations from standard barometric pressure have little effect on the correction factors (e.032 33 1.020 35 1.068 27 1.0904).124  CHAPTER 4 Gas Therapy Table 4–15 Conversion Factors to Correct Volume (ATPS) to Volume (BTPS)* Gas Temperature (8C) Factor 20 1.102 21 1.051 30 1.g.080 25 1.096 22 1.091 23 1. Note: These factors have been calculated for a barometric pressure of 760 mm Hg.063 28 1.039 32 1.014 36 1.026 34 1.045 31 1. . the factor for gas at 228C and 770 mm Hg is 1.075 26 1.007 37 1.
Gas Cylinders  125 Table 4–16 Physical Characteristics of Gases Critical Critical Density Temperature Pressure Boiling Gas (g/L) (8C) (psi) Point (8C) Air 1.29 2140.7 546.8 — Oxygen 1.43 2118.8 730.6 2182.9 Carbon dioxide 1.97 31.1 1,073.1 278.5 (sublimates) Nitrogen 1.25 2147.1 492.5 2195.8
Melting Point (8C) — 2218.4 256.6 (at 5.2 atm) 2209.9
Table 4–17 Effects of Breathing Oxygen During Hyperbaric Therapy Air Oxygen (at 1 atm) (at 1 atm) Hemoglobin concentration 0.15 kg/L 0.15 kg/L Oxyhemoglobin 200 mL 204 mL Dissolved oxygen 2.85 mL/L 13.5 mL/L Total oxygen 203 mL/L 217 mL/L
Oxygen (at 3 atm) 0.15 kg/L 204 mL 42.3 mL/L 246 mL/L
Table 4–18 Atmospheric Content, Percent by Volume Nitrogen 78.084 Oxygen 20.947 Water 0.750 Carbon dioxide 0.031
CHAPTER
Mechanical Ventilation
5
128  CHAPTER 5 Mechanical Ventilation This chapter brings together a large variety of information concerning the equipment and theory of mechanical ventilation. Some of the material has been gathered from the manufacturers’ data sheets. We have attempted to present the data in a uniform structure for easy comparison.
■■ AirwAys
Table 5–l Dimensions of Oral Airways Age ISO Size Length (mm) Neonate 4 40 Infant 5 50 Small child 6 60 Child 7 70 Small adult 8 80 Medium adult 9 90 Adult 10 100 Large adult 11 110 Guedel Pink Blue Black White Green Yellow Red Orange Berman Pink Turquoise Black White Green Yellow Purple Orange
Table 5–2 Approximate Equivalents of Various Tracheostomy Tube Jackson Size Outside Diameter (mm) French Internal Diameter (mm) 00 4.3 13 2.5 0 5.0 15 3.0 1 5.5 16.5 3.5 2 6.0 18 4.0 3 7 21 4.5–5.0 4 8 24 5.5 5 9 27 6.0–6.5 6 10 30 7.0 7 11 33 75–8.0 8 12 37 8.5 9 13 39 9.0–9.5 10 14 42 10.0 11 15 45 10.5–11.0 12 16 48 11.5
Note: Since tube thicknesses vary from one manufacturer to another, these data are intended as a guide only.
Airways  129 Table 5–3 Dimensions of Cuffless Pediatric Tracheostomy Tubes (in millimeters) Size ID OD L Portex 2.5 2.5 4.5 30 3.0 3.0 5.2 36 3.5 3.5 5.8 40 4.0 4.0 6.6 44 4.5 4.5 7.1 48 Shiley 3.0 3.0 4.5 39 3.5 3.5 5.2 40 4.0 4.0 6.0 41 4.5 4.5 6.5 42 5.0 5.0 7.1 44
ID 5 internal diameter; OD 5 outside diameter; L 5 length.
Table 5–4 Dimensions of LowPressure Cuffed Adult Tracheostomy Tubes (in millimeters) Size ID OD L Kamen–Wilkenson (Bivona) (FomeCuff) 5 5.0 7.3 60 6 6.0 8.7 70 7 7.0 10 80 8 8.0 11 88 9 9.0 12.3 98 Portex 6 6.0 8.3 55 7 7.0 9.7 75 8.0 11 82 8 9 9.0 12.4 87
0 1–2 18–20 1/4 5 5.5 4–5 26 1/4 7 .5 12.0 4.130  CHAPTER 5 Mechanical Ventilation Table 5–4 Dimensions of LowPressure Cuffed Adult Tracheostomy Tubes (in millimeters) (continued) Size ID OD L Shiley 4 5.) Size (mm) 2.0 12 3 3.5 1–2 20–22 1/4 5.4 10.9 13.0 6.0 0–0 14–16 3/16 4 4.0 8.8 81 ID 5 internal diameter.4 65 6 6.5 5.0 9.5 7.5 8.2 81 10 8.5 6.5 0–1 16–18 3/16 4.5 4. Table 5–5 Laryngoscope Blades Miller Length Age Size (mm) Premature infant 0 75 Infant 1 102 Child 2 150 Adult 3 190 Large adult — — Wisconsin Length Size (mm) 0 75 1 102 2 135 3 162 4 199 Macintosh Length Size (mm) — — 1 91 2 100 3 130 4 190 Table 5–6 Approximate Equivalents of Various Endotracheal Tube Sizing Methods* Diameter Sizing Equivalent Internal External Magill French Equivalent Connector (mm) (mm) Gauge Gauge Cuffs (in.0 3–4 22 1/4 6 6. L 5 length.8 76 8 7. OD 5 outside diameter.5 00 12–14 3.0 3–4 24 1/4 6.0 5.
0–8.0 9.5 12.0–7.5–8. One size smaller and one size larger should be available for individual variations.0 17 10–12 yr 30–32 7.5 11.5 16 7–10 yr 28–30 6.5 10.0 21 Adult (female) 34–36 8.5 10 1 yr 18–20 4.) Size (mm) 7.5 13.5–9. Table 5–7 Guide to Choice of Endotracheal Tubes* French Internal Oral Size Diameter Length (mm) (cm) .0 7.0 9.0 11.5 9.0 11.Airways  131 Table 5–6 Approximate Equivalents of Various Endotracheal Tube Sizing Methods* (continued) Diameter Sizing Equivalent Internal External Magill French Equivalent Connector (mm) (mm) Gauge Gauge Cuffs (in.5 15.5 14.0–4.0 13.0 15 4–7 yr 26–28 6.5 14 2–4 yr 24–26 5.0–5.5 8 $1000 g 14 3.5 * 9.5 10.0 5–6 6–7 7–8 8 9–10 9–10 10–11 10–11 11–12 11–12 28 30 32 34 36 38 40 42 42–44 44–46 5/16 5/16 5/16 3/8 3/8 3/8 7/16 7/16 1/2 1/2 8 9 10 11 12 13 Since tube thicknesses vary from one manufacturer to another.0 8.5 12 2 yr 22–24 5.5 20 12–16 yr 32–34 7.5–6.5 22 Adult (male) 36–38 8.0 22 * Nasal Length (cm) 11 12 14 16 17 18 19 21 23 24 25 25 Suction Catheter (French) 6 6 8 8 8 10 10 10 10 12 12 14 Endotracheal tube sizes will vary with body size and height. .5–7.1000 g 12 2.0–6.0 10.5 8.0 12. these data are intended as a guide only.0 9 6 mo 16 3.
5 2.0 1. the use of italics and subscripts differs from the symbol notation style used in this book.0 3.5 cm from predicted length. For infants weighing . Hg) Wall (mm Hg) Infant 3–5 60–100 Child 5–10 100–120 Adult 7–15 120–150 14 12 Length (cm) Nasatracheal 10 8 6 0. 5–9b. . and 5–9c and Figures 5–2 and 5–3.5 3.132  CHAPTER 5 Mechanical Ventilation Table 5–8 Appropriate Suction Settings Vacuum Settings Vacuum Settings Age Portable (in. Endotracheal (ET) tube size may be estimated for 1 to 12yearolds by internal diameter of ET tube 1mm2 5 4 age 1yr2 1 16 ■■ Definition of terms Note: In Tables 5–9a.5 4.0 2.5 1. 750 grams subtract 0.0 Oratracheal Body Weight (kg) Figure 5–1 Graph for determining the appropriate length of insertion for infant endotracheal tubes.
. Pa is alveolar pressure. surrounded by another elastic compartment representing the chest wall. consisting of a flow conducting tube (representing the airways) connected to a single elastic compartment representing the lungs. Pbs is pressure on the body surface. Ppi is pressure in the intrapleural space. Pao is the pressure at the airway opening. 1458–1470.Definition of Terms  133 Airway opening PAO Airways Ppl Pleural space Chest wall Body surface Δ Pmus PBS Lungs PA Figure 5–2 Schematic representation of the respiratory system. and DPmus is muscle pressure difference. Reprinted with permission from Respir Care 51(12) (2006).
RC = rib cage. Pa = alveolar pressure. diapgragmatic. . di = diaphragm. and abdominal wall components.134  CHAPTER 5 Mechanical Ventilation Airway opening PAO Airways PA Ppl Pleural space Chest wall Body surface Lungs Diaphragm Stomach Δ Pmus Δ Pmus di RC PBS Pab Δ Pmus ab Figure 5–3 Diagram of the respiratory system with one compartment lung(s) and chest wall subdivided into rib cage. DPmus = muscle pressure difference. Reprinted with permission from Respir Care 51(12) (2006). BS = body surface. ab = abdomen. Ppl = pressure in the intrapleural space. The arrows labeled DPmus indicate the positive directions for the corresponding muscle pressure differences. Pao = pressure at the airway opening. 1458–1470.
if no argument explicitly stated. delta symbol DP Examples pressure volume flow concentration temperature pressure at one point minus pressure at another point on the system pressure measured relative to an operating point Italic. usually Greek Bold. upper case may be English and Greek Upper and lower case Z(jv) PEEP MAP WOB PIP System response Upper and lower case FEV1 MV FVC Cdyn Reprinted with permission from Respir Care 51(12) (2006). function of angular frequency) elasticity viscosity compliance resistance time constant inertance diffusing capacity impedance (complex number. function of angular frequency) positive end expiratory pressure mean arterial pressure work of breathing peak inspiratory pressure forced expiratory volume in the first second minute ventilation forced vital capacity dynamic compliance Material Structural Bold. then time is implied) Property Not applicable Italic. . upper case.Definition of Terms  135 Table 5–9A Summary of Symbol Conventions Entity Variable Subtype Primary Style Italic. 1458–1470. upper case P V # V C T Difference (difference between points in space) Change (change relative to a reference point) Argument (used with variables only. usually English e h C R t I D System Characteristic General waveform Bold. lower case p Style of entity P(t) v(p) Z(jv) pressure as a function of time change in volume as a function of change in pressure impedance (complex number.
. 1458–1470. Reprinted with permission from Respir Care 51(12) (2006).1 *Symbols over entities such as bars.Table 5–9B Summary of Symbol Modifier Conventions* Subtype Substance PO 2 PAO Raw PO2 a 1t2 vk Entity Superscript Subscript resistance of the airways partial pressure (gauge) of oxygen in arterial blood expiratory flow (here expressed as an explicit function of time) occlusion pressure at 0. or double dots are normal mathematical conventions.1 second after start of inspiration forced expiratory volume in the first second inspiratory time interval expiratory time interval time constant t DPTR. dots.l Descriptor (inherent part Small letters (not of name) subscripted) Cdyn Vd Vt transrespiratory pressure difference at time l dynamic compliance dead space volume tidal volume mean pressure at airway opening partial pressure o oxygen Style Examples Entity Modifier (note that modifier takes on the style of the entity it modifies) Location/direction Time index FEV1 t1 tE 136  CHAPTER 5 Mechanical Ventilation Subscript P0.
# Alveolar Ventilation (VA ) The cumulative volume of fresh gas entering the gasexchanging portion of the lungs (respiratory bronchioles and alveoli) per minute. 1458–1470.Definition of Terms  137 Table 5–9C Reprinted with permission from Respir Care 51(12) (2006). Alveolar ventilation is calculated as # VA 5 1VT 2 VD2 3 fb where # VA 5 alveolar ventilation (L/min) Vt 5 tidal volume (L) Vd 5 dead space volume (L) fb 5 breathing frequency (breaths/min) .
changes in Ppl are estimated from changes in esophageal pressure. The compliance of the lung is defined as CL 5 where DVL D1PAO 2 PPL2 (5–2) Cl 5 lung compliance (L/cm H2O) DVl 5 the change in lung volume (L) Pao 5 pressure at the airway opening (cm H2O) Ppl 5 intrapleural pressure (cm H2O) (Clinically. The system for which compliance is evaluated is defined by the points between which the pressure is measured.138  CHAPTER 5 Mechanical Ventilation Compliance A property that describes the elastic behavior of a structure. It quantifies the volume change that results from a change in pressure difference across a system at rest. which comprises the lungs and chest wall.) For the chest wall. For example. we can evaluate the compliance of the physiologic system. Compliance can be calculated as the ratio of the change in volume to the change in pressure difference occurring between instants in which the system is completely at rest: C5 where DV D1PI 2 PO2 (5–1) C 5 compliance (L/cm H2O) DV 5 change in volume (L) Pi 5 pressure inside the system Po 5 pressure on the outside surface of the system Note: The symbol D indicates a change in the variable within the parentheses. the equation is CW 5 DVW D1PPL 2 PBS2 (5–3) .
with the patient connection port occluded PIP 5 peak inspiratory pressure with patient connection port occluded PEEP 5 positive endexpiratory pressure (if any) with patient connection port occluded . CRS 5 where DVL D1PAO 2 PBS2 (5–4) Crs 5 total respiratory system compliance (L/cm H2O) Equations (5–2). and (5–4) can be combined to show that 1 1 1 5 1 CRS CL CW or CRS 5 CL 3 CW CL 1 CW Another system for which a knowledge of compliance is useful is the ventilator circuit attached to the patient’s airway.Definition of Terms  139 where Cw 5 chest wall compliance (L/cm H2O) DVw 5 the change in the volume of the thoracic cavity (equal to Vl if there is no pneumothorax) Pbs 5 pressure at the body surface (cm H2O) Also. (5–3). We can compute this patient circuit compliance as CPC 5 where tidal volume tidal volume 5 D1PAO 2 PBS2 PIP 2 PEEP Cpc 5 patient circuit compliance (Pao 2 Pbs) 5 the difference between pressure at the airway opening and pressure on the body surface.
Cdyn(fb) decreases as fb increases).e. different regions of the lungs have different products of local flow resistance and local static compliance). In practice. static respiratory system compliance can be evaluated using the equation CRS 5 where Crs 5 static respiratory system compliance (L/cm H2O) Vt 5 tidal volume delivered to patient (L) Pplt 5 proximal airway plateau pressure (cm H2O) PEEP 5 positive endexpiratory pressure in the lungs (cm H2O) Another index.. the dynamic characteristic. In this case Cdynl(fb) describes the elastic load presented by the system at a particular breathing frequency and reflects both the resistances and compliances of all the lung regions. is often confused with dynamic compliance: dynamic characteristic 5 VT PIP 2 PEEP VT PPLT 2 PEEP .. then we can infer that the lungs have a uniform distribution of mechanical time constants. and if the values obtained under both sets of conditions are the same (within 20%). If Cdynl(fb) and Cl are not equal at all frequencies (i.140  CHAPTER 5 Mechanical Ventilation Compliance evaluated by equations (5–1) to (5–4) is referred to as static compliance in the literature. During mechanical ventilation. Compliance calculated in this way is called dynamic compliance. Such lungs can therefore be characterized by a single compliance (Cl) and a single resistance (Rl) at all breathing frequencies. for dynamic compliance we shall use Cdyn(fb). Static and dynamic compliances are given various symbols: For static compliance we shall use C. the equations are sometimes applied to the respiratory system during breathing.e. then the lungs have a nonuniform distribution of mechanical time constants (i. in which fb indicates that Cdyn is evaluated at particular breathing frequencies. If equation (5–2) is evaluated for the lungs when they are completely at rest (Cl) and during breathing at different frequencies (Cdynl(fb)). and the variables V and P are measured at instants when the flow at the airway opening is zero rather than when the system is at rest.
the “% inspiration” of the Siemens Servo i Ventilator). It refers to the ratio of the time that a device operates to its total cycle time expressed as a percent (e. a compressor is the device primarily responsible for generating the pressure necessary to force gas into the patient’s lungs. This component is called the anatomic dead space.g. One component of the physiologic dead space can be identified with the conducting (nongasexchanging) airways extending from the upper airway to the respiratory bronchioles.e. It should be interpreted as an index of the load experienced by the ventilator. Dead Space Volume (Vd) Dead space volume is the respired gas volume that does not participate in gas exchange. Cycle To cycle the ventilator means to terminate the inspiratory phase. As it applies to mechanical ventilators. Normal physiologic dead space volume is roughly estimated as 2 mL/ kg (1 mL/lb) of ideal body weight. the duty cycle can be defined as duty cycle 1%2 5 f 3 TI TI I 3 100% 5 3 100% 5 3 100% 60 TCT I1E duty cycle I 5 E 100% 2 duty cycle and . This index is not compliance because the pressure change has a component due to airway resistance (i.Definition of Terms  141 where PIP is peak inspiratory pressure. This volume is commonly referred to as physiologic dead space.. PIP occurs while flow is still being delivered to the airway opening). the dynamic characteristic will decrease as either airway resistance increases or compliance decreases. In mechanical ventilation. Duty Cycle A term applied to a device that functions intermittently rather than continuously. Compressor A device whose internal volume can be changed to increase the pressure of the gas it contains.. For a given tidal volume and inspiratory flow rate.
. the pressure generated by a mechanical ventilator) measured relative to endexpiratory pressure .142  CHAPTER 5 Mechanical Ventilation where f 5 ventilator frequency (breaths/min) Ti 5 inspiratory time (s) TCT 5 total cycle time. equal to endexpiratory alveolar pressure minus set PEEP Pmus 5 the effective pressure difference generated by the respiratory muscles Ptr 5 the change in transrespiratory system pressure (e. One version of this equation is During Inspiration: # PMUS 1 PTR 5 1ETR 3 V2 1 1RTR 3 V2 1 aPEEP 5 # 1ERS 3 V2 1 aPEEP 5 21RRS 3 V2 # V 1 1RRS 3 V2 1 aPEEP CRS During Expiration when Pmus and Ptr 5 0: where aPEEP 5 auto PEEP. or time for one ventilatory cycle of one inspiration and one expiration (s) I 5 numerator of inspiratory:expiratory ratio E 5 denominator of inspiratory:expiratory ratio Elastance (E) The reciprocal of compliance (C): E5 1 C Equation of Motion The respiratory system can be modeled as a single flowconducting tube connected in series to a single elastic compartment (referred to as a single compartment model). volume.g. The equation that relates pressure. and flow (all of which are functions of time) for this model is called the equation of motion.
e.Definition of Terms  143 Crs 5 compliance of the respiratory system V 5 volume change measured relative to endexpiratory volume (i.e. Expiratory Time (Te) The time interval from the start of expiratory flow to the start of inspiratory flow. constantflow ventilators. Expiratory time is the total cycle time minus the inspiratory time. and the chest wall (along with chest wall compliance and resistance) is defined in terms of transmural pressure (pressure in the pleural space minus pressure at the body surface). Te may be calculated from the following equation (assuming there is no inspiratory hold): TE 5 TI 2 TE 5 where 60 VT 2 # f VI Te 5 expiratory time (s) Ti 5 inspiratory time (s) TCT 5 total cycle time (s) f 5 ventilatory frequency (breaths/min) Vt 5 tidal volume (L) # VI 5 inspiratory flow rate (L/s) . Thus.. The equation of motion may also be expressed using transpulmonary pressure (with lung compliance and resistance) or transmural pressure (with chest wall compliance and resistance). For volumelimited. the lungs (along with lung compliance and resistance) are defined in terms of transpulmonary pressure (pressure at the airway opening minus pressure in the pleural space).. functional residual capacity [FRC]) Rrs 5 resistance of the respiratory system # V 5 change in flow measured relative to endexpiration (i. the respiratory system (along with respiratory system compliance and resistance) is defined in terms of transrespiratory pressure (pressure at the airway opening minus pressure at the body surface). relative to zero flow) Ers 5 elastance of the respiratory system The system described by the equation of motion is defined by the points in space between which the pressure difference is measured.
Ventilator (f) Breathing cycles or breaths per unit time (usually minutes) produced by a ventilator. Te is calculated as TE 5 where TCT 3 E 60 3 E 5 I1E f 3 1I 1 E2 Te 5 expiratory time (s) TCT 5 total cycle time (s) I 5 numerator of I:E ratio E 5 denominator of I:E ratio f 5 ventilatory frequency (breaths/min) Frequency. Ventilator (as related to gas exchange) During volumelimited. controlled ventilation. Breathing (fb) The number of breathing cycles or breaths per unit time (usually minutes) produced spontaneously or initiated by the patient or by the ventilator. Frequency.144  CHAPTER 5 Mechanical Ventilation If the I:E ratio is known. suppose a ventilator frequency of 10 bpm results in a Paco2 of 60 mm Hg. and a Paco2 of 40 mm Hg is desired without making a change in Vt. then new f 5 10 × 1 × 60/40 5 15 breaths/min . Assuming steady state and the body’s metabolic production of carbon dioxide remains constant. Frequency. since Paco2 is inversely proportional to alveolar ventilation. the arterial carbon dioxide tension (Paco2) can be controlled by the ventilator frequency. the ventilator frequency required to effect a desired Paco2 is given by new f 5 old f × (old Va / new Va) × (old Paco2 / new Paco2) where Va 5 alveolar volume 5 tidal volume minus dead space volume For example.
mean inspiratory flow rate can be calculated as # VT VI 5 TI where # VI 5 inspiratory flow (L/min) Vt 5 tidal volume (L) Ti 5 inspiratory time (min) . Inspiratory:Expiratory Time Ratio (I:E) Ratio of the inspiratory time to the expiratory time: I:E 5 I/E In the above equation. 1:0. Inspiration only occurs while there is flow into the airway opening. I and E can be expressed using either of the following conventions: I 5 Ti/Te E51 or I51 E 5 Te/Ti.g. g).. For volume control modes. 1:3.5) (for example. where ti 5 inspiratory time Te 5 expiratory time (for example. 2:1) # Inspiratory Flow (VI ) The flow of gas measured at the airway opening during inspiration. Inspiration The act of inflating the lungs.Definition of Terms  145 Gauge Pressure Gauge pressure is the difference between the pressure of a fluid at some point and atmospheric pressure. Gauge pressure is denoted by a lower case g (e. psig or cm H2O.
This delay period extends the inspiratory time. Ti is given by TI 5 where TCT 3 I 60 3 I 5 I1E f 3 1I 1 E2 Ti 5 inspiratory time (s) TCT 5 total cycle time (s) I 5 numerator of I:E ratio E 5 denominator of I:E ratio f 5 ventilatory frequency (breaths/min) Inspiratory Relief Valve A unidirectional valve designed to admit air to the patient system when the patient inspires spontaneously and the supply of inspiratory gases from the ventilator is inadequate. It is characterized by a delay between the end of inspiratory flow and the beginning of expiratory flow. Note that Ti can extend beyond the point when inspiration ends as when an inspiratory hold is used. Inspiratory time is equal to the total cycle time (TCT) minus the expiratory time.146  CHAPTER 5 Mechanical Ventilation Inspiratory Hold A maneuver used during mechanical ventilation. . Inspiratory Time (Ti) The time interval from the start of inspiratory flow to the start of expiratory flow. For volumelimited constant flow ventilators. Ti may be calculated from the following equation (assuming there is no inspiratory hold): VT TI 5 # VI where Ti 5 inspiratory time (s) Vt 5 tidal volume (L) # VI 5 inspiratory flow (L/s) If the I/E ratio is known.
the valve opens).e.. flow. (This may be limited by ventilator adjustments to less than Ps max. Inspiratory Triggering Volume (Vtr) The volume change of the patient system plus the patient’s lungs required to initiate the ventilator inspiratory phase.e. or volume requirements and the start of inspiratory flow. below the inspiratory triggering pressure) sufficient to initiate the ventilator inspiratory phase. but with functioning safety mechanisms (i. Maximum Working Pressure (Pw max) The highest gauge pressure that can be attained in the patient system during the inspiratory phase when the ventilator is functioning normally. Inspiratory Triggering Pressure (Ptr) The airway pressure at the patient connection port that must be generated by the patient to initiate the ventilator inspiratory phase. Inspiratory Triggering Response Time (Ttr) Time delay between the satisfaction of the inspiratory triggering pressure. For a periodic waveform. Paw is defined as Paw 5 area under pressure curve for one cycle total cycle time .Definition of Terms  147 # Inspiratory Triggering Flow (VTR ) The flow that must be generated by the patient at the patient connection port to produce a drop in pressure (i.) Mean Airway Pressure (Paw) The average pressure that exists in the airways over a given integral number of cycles during mechanical ventilation. Maximum Safety Pressure (Ps max) The highest gauge pressure that can be attained in the patient system during malfunction of the ventilator..
Minimum Working Pressure (Pw min) The most negative gauge pressure that can be attained in the patient system during the expiratory phase when the ventilator is functioning normally.) # Minute Volume (VE . Minute Ventilation) The cumulative volume of gas expired per minute by the patient: # VE 5 VT 3 f where # VE 5 minute volume (L/min) Vt 5 tidal volume (L) f 5 ventilatory frequency (breaths/min) . but with functioning safety mechanisms. the value of k is 1. PIP 5 peak inspiratory pressure (cm H2O) PEEP 5 positive endexpiratory pressure (cm H2O) Ti 5 inspiratory time (sec) TCT 5 total cycle time (sec) For a constant flow ventilator with a periodic triangular pressure waveform and negligible expiratory resistance. Paw 5 where Paw 5 mean airway pressure (cm H2O) k 5 waveform constant. (This may be limited by ventilator adjustment to a pressure that is greater than Ps min. For a periodic rectangular pressure waveform.148  CHAPTER 5 Mechanical Ventilation In general. The value of k depends on the shape of the airway pressure curve.0. the value of k in the preceding equation is 1 . Also. 2 k1PIP 2 PEEP2 3 TI TCT 1 PEEP Minimum Safety Pressure (Ps min) The most negative gauge pressure that can be attained in the patient system during malfunction of the ventilator.
During volumelimited ventilation. As it relates to a mechanical ventilator.098 3 Paw 3 V where # W 5 instantaneous ventilator power (watts) Paw 5 airway pressure (cm H2O) # V 5 flow (L/s) Note: The constant 0. airway pressure drops from its peak value to the plateau value as gas is redistributed within the lung. Plateau Pressure (PPlt) That portion of the proximal airway pressure waveform generated during positive pressure ventilation that is due solely to the elastic recoil of the total respiratory system (chest wall plus lungs). Once volume delivery from the ventilator has stopped. # Power. this pressure is generated in the lung by delivering a preset volume and delaying the opening of the exhalation valve until all airflow in the lungs has ceased. Patient System That part of the ventilator gas system (up to the patient connection point) through which respired gas travels at respiratory pressures.Definition of Terms  149 Motor Anything that produces motion. . the motor is the device used to drive the compressor. Ventilator (W ) The rate of work performed by the ventilator on the patient: # # W 5 0.098 is used to convert cm H2O ? L/s to watts. Pendelluft Gas flow between different regions of the lung caused by inequalities of mechanical time constants among these regions.
airway resistance (Raw) is a measure of the flow resistance between the airway opening and the alveoli. Resistance can be calculated as the change in pressure difference producing flow divided by the change in flow.150  CHAPTER 5 Mechanical Ventilation Pressure Drop The difference in pressure between a point of higher pressure and another of lower pressure. Pressure Hold One type of proximal airway pressure pattern produced by a positive pressure ventilator. where changes in pressure and flow are measured between points in time of equal lung volume: R5 where D1P1 2 P22 # DV (5–5) R 5 resistance (cm H2O/L/s) D(P1 – P2) 5 change in pressure difference across the system from some point 1 to another point 2 (cm H2O) # DV 5 change in flow (L/s) The system for which resistance is calculated is defined by the points between which the pressure difference is measured. airway resistance can be estimated by the equation Raw 5 where D1PAO 2 PA2 # DV (5–6) Raw 5 airway resistance (cm H2O/L/s) Pao 5 proximal airway pressure (cm H2O) . If measurements of flow and pressure are made at points of equal lung volume (so that pressure changes due to elastic recoil are canceled out). For a viscous gas flowing through a tube. Resistance (Flow Resistance) A system property that relates the pressure drop causing flow through the system. resistance arises from the interaction among gas molecules and between gas molecules and the tube wall. It is characterized by a rise in inspiratory pressure to some peak value that is deliberately sustained for the duration of the inspiratory time. For example.
Ventilator A deliberate increase in tidal volume for one or more breaths at intervals. During mechanical ventilation with a constant flow generator. Therefore. . RRS 5 where PIP 2 PPLT # VI (5–8) Rrs 5 respiratory system resistance (cm H2O/L/s) PIP 5 peak inspiratory pressure (cm H2O) Pplt 5 plateau pressure (cm H2O) # VI 5 set inspiratory flow rate (L/s) The major component of Rrs and Rl is Raw. which includes Raw and other resistances due to pulmonary and chest wall tissue motions. During mechanical ventilation.Definition of Terms  151 # V 5 change in flow (L/s) Pa 5 alveolar pressure (cm H2O) Also RL 5 where D1PAO 2 PPL2 # DV (5–7) Rl 5 lung resistance (cm H2O/L/s) # DV 5 change in flow (L/s) Ppl 5 intrapleural pressure (cm H2O) Another example is total respiratory resistance. in practice. The required pressure difference is between the airway opening and the body surface. During normal spontaneous breathing. they are often used interchangeably as close estimates of each other. the change in this pressure difference can be estimated as peak inspiratory pressure minus plateau pressure. Sigh. the sigh volume generally used is twice the tidal volume. sighs occur 6–10 times per hour. Therefore.
If an inspiratory hold maneuver is used. For example. Tidal Volume (Vt) The volume change of the patient’s lungs during spontaneous breathing or mechanical ventilation. C. Specific compliance provides a means of comparing the elastic behavior of the pulmonary parenchyma of lungs of different sizes. For volumelimited ventilation.152  CHAPTER 5 Mechanical Ventilation Specific Compliance (C/Vl) A parameter used to characterize the elastic behavior of the material from which a system is made. The tidal volume delivered to the patient is usually less than the volume set on the ventilator due to the volume lost (compressed) in the patient system: tidal volume 5 set machine volume – compressed volume The compressed volume can be calculated if the compliance of the patient circuit (Cpc) is known (see Compliance). This is in contrast to compliance. the following equation applies: tidal volume 5 ° 1 CPC ¢ 3 set machine volume 11 CRS where Crs 5 respiratory system compliance . Specific compliance is defined as C divided by the total volume of the structure at which C is evaluated. the tidal volume is controlled by ventilator settings and remains relatively constant while the pressure necessary to deliver the volume varies with changing lung mechanics. respiratory system compliance affects the change in airway pressure and hence the volume of gas compressed in the patient circuit. the compressed volume is determined by the change in airway pressure during inspiration. which characterizes the elastic behavior of a particular system constructed from the material. compressed volume 5 (PIP – PEEP) × Cpc where PIP 5 peak inspiratory pressure PEEP 5 endexpiratory pressure During mechanical ventilation. Once the patient is connected to the ventilator.
one in which all the respiratory muscles are completely relaxed or paralyzed): PTR 5 # V 1R3V C (5–9) . If a step input (instantaneous change) of pressure is applied to the airway opening of such a model.e. C 5 total respiratory system compliance (L/cm H2O) DP 5 step change in airway pressure. in physiology the respiratory system is often modeled as being composed of a single compliance (representing the chest wall and the alveoli) and a single resistance (representing the airways).. substitute the patient’s dynamic characteristic for Crs in this equation. or PIP 2 PEEP (cm H2O) e 5 the base of the natural logarithms (approximately 2. the pressure rise in the compliant chamber will be an exponential function of time. inspiratory time R 5 total respiratory system resistance (cm H2O/L/s) Note: This equation is derived from the equation describing the change in alveolar pressure in response to a step change in airway pressure (see Time Constant). consider the relation governing the mechanics of a completely passive total respiratory system (i. Time Constant (Resistance 3 Compliance) A measure of the time (usually seconds) necessary for an exponential function of time to attain 63% of its value at time equal to infinity. To illustrate this. During pressure control ventilation. If time 5 inspiratory time then V(t) 5 tidal volume.72) t 5 the time interval (in seconds) from the initiation of the step change in airway pressure.Definition of Terms  153 If an inspiratory hold is not used. The change in lung volume caused by a step change in airway pressure (rectangular pressure pattern) is given by V1t2 5 C 3 DP 3 11 2 e2t>1R 3 C22 5 CDPa1 2 1 b et>1R 3 C2 where V(t) 5 lung volume (L) as a function of time (t). For example. the proximal airway pressure pattern is controlled by ventilator settings and remains relatively constant while the tidal volume varies with changing lung mechanics.
72) t 5 the time interval (in seconds) from the initiation of the step change in airway pressure. the alveolar pressure will be 86.63. ∆P. the difference between the pressure at the airway opening and the pressure on the body surface (usually atmospheric pressure). Pa is considered in equilibrium with the pressure at the airway opening.g.7221 5 1 2 0. the time constant. we get the equation for lung volume as a function of time (see Tidal Volume). Conversely. To appreciate the properties of the time constant. equation (5–9) can be solved for alveolar (lung) pressure as a function of time. When t is equal to R × C. ∆Pao 5 PIP 2 PEEP).154  CHAPTER 5 Mechanical Ventilation in which Ptr is transrespiratory system pressure. the time necessary to attain 63% of the final response (which may be measured experimentally) is equal to the product of R and C and thus gives a mechanical characteristic . inspiratory time This states that the alveolar pressure (the pressure in the compliant chamber in our model) will undergo an exponential change in response to a step change of ∆P in airway pressure. At this time also. appears as a fundamental quantity in this equation and is therefore given its own name.37 5 0. tidal volume volume (V). that is. and # gas flow rate into the lungs (VL ). assuming resistance and compliance are constant: PA 1t2 5 DPAO 3 11 2 e2t>1R 3 C22 (5–10) where Pa(t) 5 alveolar pressure as a function of time (t) DPao 5 change in pressure at the airway opening e 5 the base of the natural logarithms (approximately 2. The product of resistance and compliance. Thus. consider the values equation (5–10) will have at specific instants of time.5% of the forcing pressure. resistance (R). the term t/RC equals 1 and the expression 1 2 e2t/R 3 C 5 1 2 2. If both sides of equation (5–10) are multiplied by C. This equation states that the pressure necessary for inflation or deflation of the lungs depends on the compliance of the total respiratory system (C). If t is equal to 2RC or two time constants. For a step change in airway pressure (e. Alveolar pressure is generally considered to be at its steadystate value when t is equal to 5RC. since all flow through the airways has essentially ceased. Expressing t as a multiple of the time constant is thus a convenient method of predicting the time necessary for the system to respond to a step input of pressure. when t equals RC. the alveolar pressure is equal to 63% of the forcing pressure. RC (which has the dimensions of time)..
TCT 5 TI 1 TE 5 where TCT 5 total cycle time (s) Ti 5 inspiratory time (s) Te 5 expiratory time (s) f 5 ventilatory frequency (breaths/min) 60 f . 100 B Alveolar Pressure (% ∆P) 80 60 40 20 A 0 1 2 3 4 5 6 Time Constants Figure 5–4 Time constant curves. Torr Unit of pressure named in honor of Evangelista Torricelli. It is generally considered to be equal to a millimeter of mercury. Curve B corresponds to expiratory lung pressure and volume and inspiratory flow. although the latter is gravitydependent. who invented the mercury barometer.Definition of Terms  155 of the system. Total Cycle Time (TCT) The time necessary for one complete respiratory cycle. Curve A corresponds to the inspiratory lung pressure and volume and expiratory flow. The torr is defined as exactly equal to 1/760 of a standard atmosphere. Figure 5–4 shows the fraction of ∆P that exists in the lungs at the end of time constants 0 through 5.
156  CHAPTER 5 Mechanical Ventilation
Trigger
To trigger the ventilator means to initiate the inspiratory time.
Work, Ventilator (W)
Work performed by the ventilator on the patient: W 5 0.098 3 where W 5 work (joules) P 5 pressure (cm H2O) # V 5 flow (L/s) 0.098 5 constant to convert cm H2O ? L to joules
#P 3 V dt
#
■■ ClAssifying moDes of meChAniCAl VentilAtion
A “mode” of mechanical ventilation can be generally defined as a predetermined pattern of interaction between a ventilator and a patient. There are over 100 names for modes of ventilation on commercially available mechanical ventilators. Neither the manufacturing community nor the medical community has developed a standard taxonomy for modes. However, we present here an approach to both defining and classifying the major characteristics of modes. It consists of 10 fundamental aphorisms that constitute the components of a practical taxonomy and ultimately, an adequately explicit definition of “mode.” The aphorisms are given in outline form below: 1. The Breath. The normal breathing pattern is cyclic and thus a breath is conveniently characterized by the phases of the flow–time waveform at the airway opening. 1.1. The positive phase of the flow waveform is designated inspiration (inspiratory phase). The negative phase of the flow waveform and the remaining time until the next inspiration indicates expiration (expiratory phase). 1.1.1. Inspiration (inspiratory time) includes the phase of positive flow and any period of zero flow before flow goes negative.
Classifying Modes of Mechanical Ventilation  157 1.1.2. Expiration (expiratory time) includes the phase of negative flow and any period of zero flow before flow goes positive for the next cycle. 2. The Assisted Breath. A ventilator can provide all of the mechanical work of inspiration or only a portion of it. 2.1. An assisted breath is one for which the ventilator does some or all of the work of breathing (i.e., transrespiratory pressure rises during inspiration or falls during expiration). 2.2. An unassisted breath is one for which the ventilator simply provides flow at the rate required by the patient’s inspiratory effort (i.e., transrespiratory system pressure stays constant throughout the breath). 2.3. A loaded breath is one for which the patient does work on the ventilator (i.e., transrespiratory pressure falls during inspiration or rises during expiration). 3. The Control Variable. Ventilators operate by manipulating a control variable. For simple control systems, where pressure, volume, or flow is preset, the control variable is the independent variable in the equation of motion for the respiratory system. In more complicated schemes, the control variable is identified according to the feedback loop that is predominant within a breath (not between breaths). For example, with Proportional Assist, pressure, volume, and flow all vary during the breath, and none of them are preset. However, the targeting scheme is designed to control pressure such that it satisfies the equation of motion for preset values of respiratory system elastance and resistance that are to be supported for any instantaneous values of inspiratory flow and volume generated by the patient’s inspiratory effort. 3.1. For historical reasons and to simplify descriptions of ventilator operation, pressure and volume are considered to be the control variables. 3.1.1. Volume is measured and controlled either directly (e.g., by the excursion of a piston) or indirectly (by integration of the flow signal). 3.2. While a ventilator can control only one variable, it may switch from volume control to pressure control or vice versa during an individual inspiration.
158  CHAPTER 5 Mechanical Ventilation 4. Trigger and Cycle Variables. During mechanical ventilation, an individual breath is classified by the criteria that start (trigger) and end (cycle) the inspiratory phase. 4.1. Inspiratory time is determined by the cycle criterion. 4.2. Expiratory time is determined by the trigger criterion. 4.3. The duration of the breath (total cycle time) is the sum of the inspiratory and expiratory times. 4.4. These criteria may be set either as static values for each breath (e.g., operator preset) or as dynamic values determined by algorithms during the course of ventilation. 5. Patient and Machine Triggering and Cycling. Trigger and cycle criteria can be grouped into two categories: machine initiated and patient initiated. 5.1. Machineinitiated criteria are those that determine the start and end of the inspiratory phase independent of the patient. This means that the ventilator determines the inspiratory time and expiratory time, or alternatively, the inspiratory time and frequency. 5.1.1. Machine triggering criteria include but are not limited to: 5.1.1.1. Frequency 5.1.1.2. Expiratory time 5.1.1.3. Minimum minute ventilation 5.1.2. Machine cycling criteria include: 5.1.2.1. Inspiratory time 5.1.2.2. Tidal volume 5.2. Patientinitiated criteria are those that affect the start and end of the inspiratory phase independent of any machine settings for inspiratory and expiratory time. This means that the patient may affect the inspiratory time and frequency. 5.2.1. Patient triggering criteria include but are not limited to: 5.2.1.1. Transrespiratory system pressure 5.2.1.2. Inspiratory volume 5.2.1.3. Inspiratory flow
Classifying Modes of Mechanical Ventilation  159 5.2.1.4. Diaphragmatic electromyogram 5.2.1.5. Transthoracic electrical impedance 5.2.2. Patient cycling criteria include: 5.2.2.1. Transrespiratory system pressure 5.2.2.2. Inspiratory flow 6. Mandatory and Spontaneous Breaths. An individual breath is classified as being mandatory or spontaneous. A mandatory breath is one for which the start or end of inspiration (or both) is determined by the ventilator, according to a preset schedule (e.g., preset frequency or minute ventilation). Mandatory breaths will begin and end without a signal from the patient but may also be synchronized with a patient signal (e.g., change in baseline pressure or flow). A spontaneous breath is one for which the start and end of inspiration is determined by the patient. Triggering and cycling of a spontaneous breath may occur due to a signal derived from active inspiratory or expiratory efforts or a signal derived from the passive behavior of the respiratory system (e.g., change in pressure or flow during inspiration or expiration governed by the time constant of the respiratory system). 6.1. Mandatory breaths are machine triggered or machine cycled or both. 6.2. Spontaneous breaths are both patient triggered and patient cycled. 7. The Breath Sequence. A breath sequence is a particular pattern of mandatory and/or spontaneous breaths. Breath sequences can be grouped into three categories: 7.1. Continuous mandatory ventilation (CMV): Mandatory breaths are patient triggered for every patient effort that satisfies the mandatory breath trigger criteria. In the absence of patient triggering, mandatory breaths will be machine triggered. Spontaneous breaths may occur during a mandatory inspiration but not between mandatory breaths. 7.2. Intermittent mandatory ventilation (IMV): Mandatory breaths are patient triggered if the patient effort satisfies the mandatory breath trigger criteria and it occurs in a brief trigger window, which typically occurs at the end of the expiratory time allowed by the preset mandatory breath frequency. Otherwise they are
160  CHAPTER 5 Mechanical Ventilation machine triggered, and spontaneous breaths may occur between mandatory breaths. 7.2.1. If the frequency of either spontaneous breaths or patienttriggered mandatory breaths is too low, mandatory breaths may be machine triggered. Three common variations of IMV are: 7.2.1.1. Mandatory breaths are always delivered at the set frequency. 7.2.1.2. Mandatory breaths are delivered only when the spontaneous breath frequency falls below the set frequency. 7.2.1.3. Mandatory breaths are delivered only when the spontaneous minute ventilation (i.e., product of spontaneous breath frequency and spontaneous breath tidal volume) drops below a preset or computed threshold (also known as mandatory minute ventilation). 7.2.2. Spontaneous breaths may occur during a mandatory inspiration. 7.3. Continuous spontaneous ventilation (CSV): Every breath is spontaneous. 8. The Ventilatory Pattern. A ventilatory pattern is a specification for a particular control variable associated with a particular breath sequence. There are five basic ventilatory patterns: 8.1. Volumecontrolled continuous mandatory ventilation (VCCMV) 8.2. Volumecontrolled intermittent mandatory ventilation (VCIMV) 8.3. Pressurecontrolled continuous mandatory ventilation (PCCMV) 8.4. Pressurecontrolled intermittent mandatory ventilation (PCIMV) 8.5. Pressurecontrolled continuous spontaneous ventilation (PCCSV) 8.5.1. All forms of CSV are either uncontrolled (i.e., the ventilator does nothing) or forms of pressure control. Therefore PCCSV may be abbreviated as CSV. 9. Targeting Schemes. During inspiration, the control variable can be manipulated by a variety of feedback control or targeting schemes. These schemes can be ranked according to complexity and degree
and other relevant operational algorithms. the ventilatory pattern. and species taxonomy for animals.2. and the targeting scheme are the levels of a taxonomy for modes of ventilation analogous to the family... the ventilator adjusts peak inspiratory pressure to achieve an average preset target tidal volume). such as “pressure support” or “SmartCare. based on the preset parameters.e.g. Modes of Ventilation.1.1. the trigger and cycle criteria. volume.Classifying Modes of Mechanical Ventilation  161 of required operator intervention. therefore.” 10.. is a complete specification for preset ventilatorpatient interaction. Model parameters are preset by the operator. A mode may also be referred to by a name. and timing parameters and the ventilator switches between volume control and pressure control. Modes within a particular ventilatory pattern are distinguished by their targeting scheme. 9. A mode description comprises a unique combination of control variable. Intelligent control: the ventilator automatically adjusts one or more setpoints based on an artificial intelligence program. the equation of motion). 10. flow. Common examples include the following: 9. 10.. and any . 9.3. Any mode of ventilation can be associated with one and only one ventilatory pattern.5.6. and timing) 9.2. flow. targeting scheme. genus.e. 9. Parameters of the model may be preset by the operator. 9. Dual control: the operator presets pressure. BiPAP and Adaptive Support Ventilation are different modes of the PCIMV ventilatory pattern in the pressure control family just as lions and tigers are different species in the genus panther in the family of cats. pressure. Adaptive control: the ventilator automatically adjusts one or more breath setpoints based on other operator preset criteria (e.g. volume or pressure). volume. Setpoint control: the operator is required to preset all parameters of the breath (i. within a single breath. ventilatory pattern. For example. Optimum control: the ventilator automatically adjusts one or more setpoints based a model that attempts to minimize or maximize some other variable(s). The control variable (i. Servo control: the ventilator delivers pressure in proportion to the patientgenerated volume and/or flow according to a preset model (e.4. A mode of ventilation.
CSV 5 continuous spontaneous ventilation. Adaptive Support Ventilation VC 5 volume control. The finer the distinction required. CMV+AutoFlow Pressure SetPoint Airway Pressure Release Ventilation SIMV Control PCV. . (S)CMV. the more levels of criteria that are needed. HFJV CMV Adaptive Pressure Regulated Volume Control. PCV+ IMV Adaptive VC + SIMV. Mandatory Minute Volume SetPoint Pressure Control. VCSIMV Dual SIMV + Pressure Limited IMV Adaptive AutoMode (VCVS). CMV. BiLevel. VC+A/C. Table 510 shows how this system can be used to classify a variety of modes of ventilation. Automatic CSV Control Tube Compensation Adaptive Volume Support Intelligent SmartCare. Table 5–10 A selection of modes named by manufacturers classified using the taxonomy built from the 10 aphorisms Control Breath Targeting Example Modes Variable Sequence Scheme SetPoint Volume Control. SIMV + AutoFlow.162  CHAPTER 5 Mechanical Ventilation other unique operational algorithm feature. PCA/C. IMV 5 intermittent mandatory ventilation. PC 5 pressure control. AC PCV. Assist/Control CMV Dual CMV + Pressure Limited Adaptive Adaptive Flow Volume Control SetPoint SIMV. VCA/C. Pressure Support Dual Volume Assured Pressure Support Pressure Servo Proportional Assist Ventilation. HFO. PiPAP S/T. CMV 5 continuous mandatory ventilation. Automode (PRVCVS) Optimal Adaptive Support Ventilation SetPoint CPAP. V V + SIMV. DuoPAP.
rate of work (J/min) inspiratory time constant (s) 5 C ? Ri expiratory time constant (s) 5 C ? Re peak inspiratory pressure above set PEEP (cm H2O) alveolar pressure above set PEEP (cm H2O) mean airway pressure above set PEEP (cm H2O) mean alveolar pressure above set PEEP (cm H2O) preset constant inspiratory pressure above preset PEEP during pressure controlled ventilation (cm H2O) preset positive endexpiratory airway pressure endexpiratory alveolar pressure or autoPEEP (cm H2O) Model Assumptions 1. The pressure applied to the airway opening rises immediately to Pset during inspiration and falls immediately to PEEP during expiration.Mathematical Models of PressureControlled Mechanical Ventilation  163 ■■ mAthemAtiCAl moDels of PressureControlleD meChAniCAl VentilAtion Reference: J Appl Physiol 67(3) (1982). Glossary C D f Re Ri Te Ti TCT # VE Vt W # W tI tE PIP Pa PAW PA Pset PEEP Pee compliance (L/cm H2O) inspiratory time fraction (Ti/Ttot) frequency (breaths/min) expiratory resistance (cm H2O ? L21 ? s) inspiratory resistance (cm H2O ? L21 ? s) expiratory time (s) inspiratory time (s) total cycle time (s) 5 Ti + Te 5 f/60 minute ventilation (L/min) tidal volume inspiratory work per breath (J) power of breathing. passive conditions exist throughout the ventilatory cycle. The pressure applied at the airway opening represents the entire pressure difference acting on the respiratory system. . a rectangular pressure–time waveform is assumed. 1081–1092. 2.
Compliance (L/cm H2O) f. L) d. Resistance (cm H2O s L 1) e. The units for each variable are those commonly used clinically: a. Volume (liters. Pressure (cm H2O) c. s) b. assuming PEE °⁄ 0 VT PSET C 1 1 PSET C 1 1 VE e f C1 PSET e 1 TE TE e e TI TI I I 1 TE E e TE E e VT e e E 60D fRIC 1 60 1 e 60 1 D fREC 60D fRIC e D fREC PEE e E TE E PEEP e TI E I VT e C1 PEEP TE E e TE E PEEP PEE 1 I e TI e TE . Frequency (breaths/min) For inspiration. assuming PEE Vt PA t VI t C PSET e PSET e 0 t E t E PEEP t E PSET e RI General equations. assuming PEE Vt PA t VI t 0 e e t I t I t I C PSET 1 PSET 1 PSET e RI PEEP For single expiration. Time (seconds.3.
PEE PA VE e f C 1 TCT C VT 60 1 D fREC D fREC e 60 1 PEEP VT e C 1 60 1 D fREC D fREC e VEE 60 1 PEEP TI I PSET C TI VEE E PSET C TE E I 1 e 1 e PEEP where VEE VT e 1 e TE TE E E PA W W PSET 1 1 e TI I eTI e I TE E PEEP eTI I C PSET PSET f C PSET PSET PEE 1 PEE 1 eTI I .
.
CHAPTER Mathematical Procedures 6 .
This is to prevent confusion when evaluating expressions such as 2 3 32. chemistry. including the section on descriptive statistics. and engineering.168  CHAPTER 6 Mathematical Procedures The multidisciplinary approach to medicine has incorporated a wide variety of mathematical procedures from the fields of physics. Distributive Axiom a(b + c) 5 ab + ac A coefficient (multiplier) of a sum may be distributed as a multiplier of each term. The following rules apply: . ■■ Fundamental axioms Commutative Axiom a+b5b+a ab 5 ba When two or more numbers are added or multiplied together. Associative Axiom (a + b) + c 5 a + (b + c) (ab)c 5 a(bc) When three or more numbers are added together. The information presented in this chapter is designed as a selfteaching refresher course to be used as a review of basic mathematical procedures. Order of Precedence A convention has been established for the order in which numerical operations are performed. Some of the more advanced mathematical concepts. which could be either 18 or 36. the way they are grouped or associated makes no difference in the result. their order does not affect the result. The same holds true for multiplication. should also help the practitioner to interpret data presented in medical journals and scientific articles.
b. Multiplication or division. Multiplication Property of Fractions a 3 c a 5 1c 2 02 b 3 c b The numerator and denominator of a fraction may be multiplied or divided by the same nonzero number to produce a fraction of equal value. 3 ).. Example 4 3 5 + 8 ÷ 2 + 62 2 216 + 1 5 20 + 4 + 36 – 4 + 1 5 57 2. If the numerical expression does contain fences. then operations are carried out in the following order: a. . Addition or subtraction. Once the fences have been eliminated. starting with the innermost set of parentheses. Example 2 + 4 3 {3 3 2 – [5 3 4 + (2 3 3 – 4 ÷ 1) – 20] + 12} 5 2 + 4 3 {3 3 2 – [5 3 4 + (6 – 4) – 20] + 12} 5 2 + 4 3 {3 3 2 – [5 3 4 + 2 – 20] + 12} 5 2 + 4 3 {3 3 2 – [20 + 2 – 20] + 12} 5 2 + 4 3 {3 3 2 – 2 + 12} 5 2 + 4 3 {6 – 2 + 12} 5 2 + 4 3 16 2 + 64 5 66 ■■ Fractions When a number is expressed as a fraction (e. c. then follow the procedure in Rule 1.g. the expression can be evaluated following Rule 1. If the numerical expression does not contain fences (such as parentheses). the number above the line 5 (3) is called the numerator and the number below the line (5) the denominator. The sequence is round fences (parentheses). double fences {braces}. square fences [brackets]. Raising numbers to powers or extracting roots of numbers.Fractions  169 1.
Multiply the denominators. 3. Simplify the resulting fraction if possible.170  CHAPTER 6 Mathematical Procedures Example Simplify (reduce) the fraction Solution 1. Multiply the numerators. Find the largest integer that will evenly divide both the numerator and denominator. 9 12 9 3 5a b 4 a b5 12 3 3 4 Multiplication of Fractions a c ac 3 5 b d bd Example 7 3 3 5? 9 4 Solution 1. 9 12 The largest whole number is 3. 2. 2. 7 3 3 5 21 9 3 4 5 36 7 3 21 3 5 9 4 36 7 5 12 Division of Fractions a c a d ad 4 5 3 5 c b d b bc . Divide both the numerator and denominator by that number.
Multiply the dividend by the inverted divisor. Simplify if possible. 2 5 4 8 3 Change 2 3 to 3 2 5 3 15 3 5 8 2 16 Addition and Subtraction of Fractions with the Same Denominator 1a 1 c2 a c 1 5 b b b 1a 2 c2 c a 2 5 b b b Example 5 13 3 1 2 5? 32 32 32 Solution 1. 2. 3. 3. Simplify if possible. Combine numerators. Write the resultant fraction with the new numerator and the same denominator. Invert the divisor. 5 + 13 2 3 5 15 15 32 . 2.Fractions  171 Example Find the quotient: Solution 1.
.172  CHAPTER 6 Mathematical Procedures Addition and Subtraction of Fractions with Different Denominators To add or subtract fractions that do not have the same denominator. 4. Express each denominator as the product of primes (integers greater than 1 that are evenly divisible by only themselves and 1). First find the LCD as follows: a. Write fractions as equivalent fractions with denominators equal to the LCD. 22 is the greatest power of 2 in either denominator. a.64 c. The product of the integers noted in part b is the LCD. 32 is the greatest power of 3 in either denominator. 22 3 32 5 36 5 9 45 3 5 4 9 36 7 2 14 3 5 18 2 36 45 14 59 + 5 36 36 36 5 1. Combine the numerators and use the LCD as the denominator. c. 2. Note the greatest power to which an integer occurs in any denominator. Simplify if possible. 4 5 2 3 2 5 22 18 5 2 3 3 3 3 5 2 3 32 b. b. it is first necessary to express them as fractions having the same denominators. To find a common denominator. The smallest or least common denominator (LCD) is the most convenient. Example 5 7 1 5? 4 18 Solution 1. 3. find an integer that is evenly divisible by each denominator.
To change the units of a quantity. 2. Example Convert 2 kilometers/hour to feet/second.000 m 6. Thus. Proportions.600 s s .600 ft 2 km 3. 2 km/hr 5 x ft/s 1 km 5 1. and unit conversion The ratio of two numbers may be written as follows: a/b 5 a:b Two equivalent ratios form a proportion. Write an equation expressing the problem. ProPortions. Solution 1. Multiply the known quantity by ratios whose value is equal to 1. Select the dimensions of the ratios such that the unit to be changed occurs as a factor of the numerator or as a factor of the denominator.8 ft 3 3 3 3 5 5 hr 1 km 1m 60 min 60 s 3.Ratios. when the quantity is multiplied by the ratio. a/b 5 c/d a:b 5 c:d a:b :: c:d Regardless of how the above proportions are expressed. multiply by ratios whose values are equal to 1 (which does not change the value of the quantity).000 m 1 m 5 3.” Ratios provide a convenient method for converting units. such that the desired unit remains after canceling pairs of equal dimensions that appear in both the numerator and the denominator.281 ft 1 hr 5 60 min 1 min 5 60 s 1. they are read “a is to b as c is to d. the unit is canceled and replaced by an equivalent unit and quantity. and Unit Conversion  173 ■■ ratios.3 ft 1 hr 1 min 1.
(a ? 0) 9x0 5 9 1 3x1 5 3x a 5a 2n n x22 5 1/x2 a 5 1/a a1/n 5 2a n n am/n 5 2am (am)n 5 amn 3 y1/3 5 2y 3 z2/3 5 2z 2 (w2)3 5 w6 ■■ scientiFic notation A number expressed as a multiple of a power of 10. In general. multiplied by a power of 10 called the exponent.000 m. However. such numbers are expressed in the form an. it is convenient to use a shorthand notation that shows the number used as a factor (a) and the number of factors (n) in the product.174  CHAPTER 6 Mathematical Procedures ■■ exPonents When a product is the result of multiplying a factor by itself several times.000 5 6. Scientific notation clarifies the number of significant figures in a large number. It simplifies the expression of very large or very small numbers that would otherwise require many zeros. if the radius of the earth is written as 6. For example.81 3 108 and 0. 681.378.000. . c. For example.378 3 106 m. The rules for these numbers are shown in Table 6–7. it is not clear whether any of the zeros after the 8 is significant. is said to be written in scientific notation.02 3 105. such as 3. it is understood that only the first four digits are significant. Numbers written in this way have two parts: a number between 1 and 10 called the coefficient. when the same number is written as 6. Calculations that involve very large or very small numbers are greatly simplified using scientific notation.000026 5 2. b.6 3 1025. This notation has three distinct advantages: a. where a is the base and n the exponent. Table 6–7 Rules for Exponents Rule Example n m n1m 2 x ? x3 5 x5 a ? a 5a n m n2m a ÷a 5a z7 ÷ z5 5 z2 n n n (ab) 5 a b (2wy)2 5 4w2y2 a0 5 1.
6 3 1011 .9 3 102 – 5.0 3 101 Solution 1. Multiply the exponent by the indicated power. Add or subtract the coefficients and retain the same exponent in the answer.18 3 103 1.18 3 103 + 1. (4 3 105)2 5 (42)(105)2 5 16(105)2 16(105)2 5 16(105 3 2) 5 16 3 1010 5 1.Scientific Notation  175 Addition and Subtraction Example 6. 2.18 3 103 1 0.05 3 103 6.18 3 103 5 6. Multiply (or divide) the coefficients.32 3 103 Multiplication and Division Example (4 3 1023)(2 3 1014) Solution 1. 2.0 3 101 5 0.9 3 102 5 0. Raise the coefficient to the indicated power.19 3 103 5. (4 3 1023)(2 3 1014) 5 8(1023 3 1014) 8(1023 3 1014) 5 8 3 1023 + 14 5 8 3 1037 Powers and Roots Example (4 3 105)2 Solution 1. Combine the powers of 10 using the rules for exponents. 2.19 3 103 2 0. 6. Convert all numbers to the same power of 10 as the number with the highest exponent.05 3 103 6.
The use of significant figures to indicate the accuracy of a result is not as precise as giving the actual error.2 cm. If the measurement is reported as 35. 2.600 0.0 28. The number of reliably known digits in a measurement is the number of significant figures. can be any number (5. 9. it would indicate that the error is even less (0.09 1 significant figure 0. 6. 4). 8.20 cm.20 cm has four. The number of significant figures is independent of the decimal point. The last digit (2) in the reported measurement is uncertain. 1. but is sufficient for most purposes.01 6 significant figures . For example.2 cm and 0.8070 4 significant figures 6000. the number 35. and the number 35.176  CHAPTER 6 Mathematical Procedures ■■ signiFicant Figures By convention. zeros between the decimal point and the first digit are not significant: 0.. 3.30 4 significant figures 5 significant figures 2 significant figures For numbers less than one. the error is about 0. Thus.2 cm has three significant figures. both having three significant figures and expressing the same degree of accuracy.5 3 significant figures 0. Zeros as Significant Figures Final zeros to the right of the decimal point that are used to indicate accuracy are significant: 179. however. 7.05 cm).e.00010 2 significant figures Zeros between digits are significant: 10. 0.15 and 35. one would assume that the true length was between 35. The digit to the right of 2. The numbers 35.352 m are the same quantities. although one can reliably state that it is either 1 or 2.005 cm). the number of digits used to express a measured number roughly indicates the error. if a measurement is reported as 35.24 cm (i.
. indicating that there are four significant figures. 0. If the digit to be dropped is a 5. If the final digits of the number are 1.2.290 3 107.5) is accurate to only one decimal place.6. Calculations Using Significant Figures The least precise measurement used in a calculation determines the number of significant figures in the answer. This is done so that one does not infer an accuracy in the result that was not present in the measurements. As an example. in 28. the term with the fewest significant figures is 4.008.6.5 + 0. For instance.9 rather than 73. making all digits significant. the rule of thumb is: The product or quotient has the same number of significant figures as the term with the fewest significant figures. For multiplication or division. Thus.e.418 5 73. Thus. a value of 50 mL measured with a graduated cylinder would be expected to have two significant figures owing to the greater accuracy of the measurement.4 and 6. 2. the result should be rounded off to 1.6268. Since this number has at most two significant figures.000 miles. since the least precise number (73. Similarly. Using this convention. respectively. although the accuracy may be only ±5000 miles. 8. If the final digits are 6.900. the final zeros may or may not be significant. 92.000 would be written 9.900. they are dropped and the preceding figure is increased by one).45 and 6. 7.6/79. This would make only the first zero after the 9 significant. with only one significant figure. the distance between Earth and the sun might be written as 92. On the other hand. 3. 2.08 3 4. numbers are often written as powers of 10 (scientific notation). The following rules are universally accepted and will ensure biasfree reporting of results (the number of significant figures desired should be determined first). 2.4 5 1. 73. Rounding Off The results of mathematical computations are often rounded off to specific numbers of significant figures. . To avoid ambiguity.394 – 0.Significant Figures  177 If a number is written with no decimal point. they are rounded up (i. 1. 3.918.15 are rounded off to 2.3862 5 0. or 9. it is rounded down if the preceding figure is even and rounded up if the preceding figure is odd. they are rounded down (dropped) and the preceding figure is retained unaltered. or 4.
178  CHAPTER 6 Mathematical Procedures ■■ Functions A function is a particular type of relation between groups of numbers. 6–1).3x + 1. The uniqueness of a function is that each member of one group is associated with exactly one member of another group. y is said to be a function of x and is denoted y 5 f(x). Linear Functions One of the simplest functions is expressed by the formula y 5 ax . In general. x is called the independent variable and y the dependent variable. 10 9 8 7 Y – axis 6 5 4 3 2 1 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 X – axis y = f(x) Figure 6–1 Graphic representation of the function y = ƒ(x). then this relation is a function. where ƒ(x)= 0. The function is plotted as a series of points whose coordinates are the values of x with their corresponding values of y as determined by the function. y 5 0 (Fig. Specifically. let the variable x stand for the values of one group of numbers and the variable y stand for the values of another group. With this notation. If each value of x is associated with a unique value of y. A function may be represented graphically by using a twodimensional coordinate (Cartesian) plane formed by two perpendicular axes intersecting each other at a point with coordinates designated as x 5 0. The vertical axis denotes values of y and the horizontal axis values of x.
2. 4. . 5.. The graph of the equation y 5 ax is a straight line.Functions  179 where y and x are variables a is a constant The constant a is sometimes referred to as the constant of proportionality and y is said to be directly proportional to x (if y is expressed as y 5 a/x. Use inverse operations to undo remaining additions and subtractions (i. multiply both sides by the least common denominator. Combine similar terms. use inverse operations to find the value of the variable. Check the result by substituting the value into the original equation. The constant a is the slope of the line. 1. Get all terms with the unknown variable on one side of the equation. y is said to be inversely proportional to x and the function is no longer linear). add or subtract the same quantities to both sides of the equation). If there are multiplications or divisions indicated in the variable term.e. 3. General Linear Equation y 5 ax + b where y 5 dependent variable a 5 slope x 5 independent variable b 5 yintercept (the value of y at which the graph of the equation crosses the yaxis) Solving Linear Equations To solve a linear equation. If the equation involves fractions.
13x 5 117 13x 117x 5 13 13 x59 3. 2x 17 3 2x 1 7 1 32 3 2x 1 39 3 2x 3 10x 2 32 1 32 5 5x 1 10x 5 5x 1 15x 2 2x 5 117 4. 8 1 10(9) 2 40 5 3(9) 1 7 1 2(9) 1 8 1 90 2 40 5 27 1 7 1 18 1 6 58 5 58 2192 3 ■■ Quadratic eQuations A function of the form y 5 ax2 is called a quadratic function.180  CHAPTER 6 Mathematical Procedures Examples 1. 3 a5x 2 10x 2 5x 2 5x 2 2x b 5 3(39) 3 2x 5 39 3 2x 5 39 3 5. 8 1 10x 2 40 5 3x 1 7 1 2x 1 10x 2 32 5 5x 1 2. and c are constants . It is sometimes expressed in the more general form y 5 ax2 + bx + c where a. b.
Write the equation in standard form. Therefore.33 or 1 5 10 . Simplify. The solution of any quadratic equation expressed in standard form may be found using the quadratic formula: x5 where a. x5 10 . 3. the quadratic equation is expressed in standard form: ax2 + bx + c 5 0 2b . b. Frequently. Substitute these values in the quadratic formula: 2b . c 5 7 x5 4.Quadratic Equations  181 The graph of this equation is a parabola. 2. b 5 210. and c are the coefficients in the quadratic equation Example Solve 3x2 + 7 5 10x Solution 1. and c. 2b2 2 4ac 2a with a ? 0. 2100 2 84 6 . 2b2 2 4ac x5 2a 3x2 2 10x + 7 5 0 212102 . Note the coefficients a. 212102 2 2 4132172 2132 a 5 3. to find the values of x where the graph intersects the xaxis. The value of y at any point on the xaxis is zero. it is of interest to know where the parabola intersects the xaxis. b. 216 6 5 2.
0.182  CHAPTER 6 Mathematical Procedures ■■ logarithms The logarithm of a number (N) is the exponent (x) to which the base (a) must be raised to produce N.5638 x 5 0.5843 log x 5 5. x 10 5 1 101 5 10 102 5 100 0 log x log 1 5 0 log 10 5 1 log 100 5 2 Table 6–1 Rules of Common Logarithms Rule 1. For example. In this book. log10 86 5 1. Table 6–1 shows the general rules of common logarithms. the base number will be omitted with the assumption that log means log10.4362 5 3. called the characteristic. Common Logarithms Common logarithms are those that have the base 10. called the mantissa (e.. b . if ax 5 N then loga N 5 x for a . Logarithms are written as numbers with two parts: an integer.400 x 5 1/273 log x 5 2log 273 5 22. 0) 2.g. log ab 5 log a + log b (a .8727 log 384 5 2. 0 and a ? 0. Thus.003663 . log 1/a 5 2log a (a .9345). log2 8 5 3 (read: the log to the base 2 equals 3) because 23 5 8.4570 x 5 286. 0) Example x 5 (746)(384) log x 5 log 746 + log 384 log 746 5 2. and a decimal.
3222 log x 5 1.5575) or 8. the exponent is used as the characteristic.025 3 102 30. 0.61 3 1022 5 2. . Once in this form.5575 – 10.0361 5 log 3.025 3 1021 Characteristic 3 2 1 0 21 Note: The characteristics of logarithms of numbers less than 1 can be written in several ways. b . The characteristic of a number can easily be found by expressing the number in scientific notation. n is a real number) 5 (374)1/3 log x 5 1/3 log 374 log 374 5 2. log 0.025 3 103 302.0361 5 –1.025 3 101 3.025 3 100 0.025 5 3.3025 5 3. log a/b 5 log a 2 log b x 5 478/21 (a .5729) 5 0. Written as a negative number (as with handheld calculators) log 0. log a 5 n log a x 5 2374 (a .204 The Characteristic The integer or characteristic of the logarithm of a number is determined by the position of the decimal point in the number.6794 log 21 5 1.3572 x 5 22.76 n 3 4.Logarithms  183 Table 6–1 Rules of Common Logarithms (continued) Rule Example 3. Thus.4425.8576 x 5 7. 0) log x 5 log 478 2 log 21 log 478 5 2. Examples Number 3025 5 3. 0.5 5 3.5729 log x 5 1/3(2.5575 (not –2.25 5 3.
a negative logarithm must be changed to a log with a positive mantissa to find its antilog.0969.6415 add 1 to the mantissa.6415 Solution 1.7.0969. Antilogs of Negative Logarithms Using a calculator. + 1 5 22 1 0. For example.02283 . the logarithms of 1. Antilogarithms The number having a given logarithm is called the antilogarithm (antilog). 4. However. The mantissa of a series of digits is the same regardless of the position of the decimal point. 2.3585 3. Therefore. Therefore. Subtract 1 from the characteristic and 21 2 0.01. Use the tables to find the antilog. Write the log as a negative character21.6415 5 21 2 0.0969 is 102. which is 0. which does not alter the original value of the logarithm. the antilog of –2 is 1022 5 0. This change of form is accomplished by first adding and then subtracting 1. antilog 21.184  CHAPTER 6 Mathematical Procedures The Mantissa The mantissa is the decimal part of the logarithm of a number. The logarithm of 125 is approximately 2. 17.3585 5 0. negative logarithms can be solved simply by using the 10x key. Express the result as a log having a 22 1 0. which is approximately 125. log and antilog tables in reference books are used with positive mantissas only. Thus. and 170 all have the same mantissa.3585 5 2. Example Find antilog 21. the antilog of 2.230.6415 istic minus the mantissa.6415 5 21 2 1 2 0.3585 negative characteristic and a positive mantissa.6415 5 antilog 2.
0) (a . The same rules apply to natural logarithms that apply to common logarithms. ln e 5 1 6. ln ex 5 x 5 eln x 7. x is a real number) (a . 0. log a x 5 log b x log b a . it is convenient to rewrite the function with the number e as a base.Logarithms  185 Natural Logarithms When a logarithmic function must be differentiated or integrated. ln 1/a 5 2 ln a 3. Logarithms which have the base e are called natural logarithms and are denoted by ln (read: “ellen”). See Table 6–2. b . then loge N 5 ln N 5 x Any number of the form a x may be rewritten with e as the base: a x 5 e x ln a Note: e x is sometimes written as exp(x). 0) (a . b . ln ax 5 x ln a 5. 0.3026(log x) (a . If e x 5 N. 0) (x . ln ab 5 ln a + ln b 2. The number e is approximately equal to 2. 0) Change of Base Logarithms to one base can easily be changed to logarithms of another base using the following equation. 0.71828. ln a/b 5 ln a 2 ln b 4. ax 5 ex ln x 8. 0) (a . ln x 5 (ln 10)(log x) 5 2. Table 6–2 Rules of Natural Logarithms 1.
302585 log10x ■■ trigonometry Systems of Angular Measure Degree The degree is defined as 1/360 of a complete revolution. an angle u in radians is given by u5 where s 5 arc length r 5 radius Relationship Between Degrees and Radians 1 revolution 5 2p radians p 5 3.14159 .53 radian 308 5 p/6 radians 458 5 p/4 radians 608 5 p/3 radians 908 5 p/2 radians 1808 5 p radians s r . . In general.186  CHAPTER 6 Mathematical Procedures Example log10x 5 logex ln x 5 loge10 ln 10 6 ln x 5 2.0174. . 1 degree 5 2p/360 radians 5 0. 1 revolution 5 3608 1 right angle 5 908 1 degree 5 60 minutes (609) 1 minute 5 60 seconds (600) Radian The radian is defined as the angle subtended at the center of a circle by an arc whose length is equal to the radius of the circle.
The angle is positive if it is generated by a counterclockwise rotation from the xaxis and negative for a clockwise rotation. The trigonometric functions of a positive acute angle u can be defined as ratios of the sides of a right triangle: sine of u 5 sin u 5 y/r cosine of u 5 cos u 5 x/r tangent of u 5 tan u 5 y/x cotangent of u 5 cot u 5 x/y secant of u 5 sec u 5 r/x cosecant of u 5 csc u 5 r/y These functions can also be expressed in terms of sine and cosine alone: tan u 5 sin u/cos u cot u 5 cos u/sin u sec u 5 1/cos u csc u 5 1/sin u Y r X y x Positive θ Negative Figure 6–2 An angle is generated by rotating a ray (or halfline) about the origin of a circle. an angle is considered positive if it is generated by a counterclockwise rotation from standard position. and negative if it is generated by a clockwise rotation (Fig.Trigonometry  187 Trigonometric Functions In trigonometry. 6–2). .
188  CHAPTER 6 Mathematical Procedures Basic Trigonometric Identities sin2u + cos2u 5 1 sec2u 5 1 + tan2u ■■ Probability The probability of an event A is denoted p(A). It is defined as follows: If an event can occur in p number of ways and can fail to occur in q number of ways. then p(A and B) 5 p(AB) 3 p(B) where p(AB) 5 the probability of event A given that event B has occurred . Addition Rule If A and B are any events. and the addition rule can be simplified to p(A or B) 5 p(A) + p(B) Multiplication Rule If A and B are any events. then the probability of the event occurring is p/(p + q). they are said to be mutually exclusive. The odds in favor of an event occurring are p to q. then p(A or B) 5 p(A) + p(B) – p(A and B) Example The probability of drawing either a king or a black card from a deck of 52 playing cards is p(king or black card) 5 p(king) 1 p(black card) 2 p(king also black) 5 4/52 1 26/52 2 2/52 5 7/13 Note: If events A and B cannot occur at the same time.
the two events are said to be independent. and the multiplication rule can be simplified to p(A and B) 5 p(A) 3 p(B) Factorial Notation(!) A number such as n! (read: n factorial) is defined by the equation n! 5 n(n – 1)(n – 2) . Note: If the occurrence of event B is in no way affected by the occurrence or nonoccurrence of event A (e. The first card is not replaced before the second card is drawn. (1) where 0! 5 1 and n is a positive integer Example 5! 5 5 3 4 3 3 3 2 3 1 5 120 Permutations Each arrangement of all or a part of a set of objects is called a permutation. The total number of permutations of n different objects taken r at a time is nPr 5 n! 1n 2 r2! .. if the first card drawn was replaced before the second card was drawn in the preceding example).Probability  189 Example Two cards are drawn from a deck of 52 playing cards. p(AB) 5 3/51. . since there are only 3 aces left of 51 remaining cards. .g. The probability that both cards are aces is given by p(both aces) 5 p(2nd card is acelst card is ace) 3 p(lst card is ace) 5 3/51 3 4/52 5 1/221 Notice that if the first card is an ace.
It is more stable than the mode or median. without regard to the order of arrangement of the objects in a group. Median The median is the point on a numerical scale that has as many items above it as below it.190  CHAPTER 6 Mathematical Procedures Combinations Each of the groups that can be made by taking all or a part of a set of objects.” it is unstable (fluctuates with sample selection) and therefore has limited use. While the mode is a quick and easy method of determining central tendency or “average. The median is an index of “average” position in a distribution of numbers. X5 where S 5 the sum of X 5 individual raw score n 5 number of scores SX n . is called a combination. The total number of combinations of n different objects taken r at a time is n Cr 5 n! r!1n 2 r2! ■■ statistical Procedures Mode In a distribution. m) The mean is the index of central tendency that is most often referred to as an average. the numerical value that occurs most frequently is called the mode. It is insensitive to extreme values and is therefore the preferred index of central tendency when the distribution is skewed and one is interested in a “typical” value. Mean (X.
the stronger the relationship. with the sample taken to be population) (used to estimate the standard deviation of a population from the sample data extracted from that population) Sx2 Å n s5 where S 5 the sum of x 5 deviation score (the difference between an individual score and the mean) n 5 number of scores Correlation Coefficient (Pearson r) The correlation coefficient is a measure of the degree of association between two variables. Standard Deviation (s. The equations are s5 Sx2 Ån 2 1 (used when finding the standard deviation of a population. It should be noted that a high degree of correlation does not necessarily mean that one variable causes the other. the Pearson r. The values of a correlation coefficient range from –1.0 (perfect positive or direct relationship). can be computed as r5 where r 5 the correlation coefficient for variables X and Y x 5 deviation score for X (the difference between an individual score and the mean) Sxy nsx sy .Statistical Procedures  191 Note: X denotes the mean of a sample.0 (perfect negative or inverse relationship) through 0 (no relationship) to +1. s) The standard deviation is the most widely used measure of variability (the extent to which scores deviate from each other). The higher the absolute value of the coefficient. The most commonly used correlation index. while m represents the mean of a population.
the more accurate the prediction. The basic linear regression equation is a formula for making predictions about the numerical value of one variable based on the scores of another variable: Y9 5 a + bX where Y9 5 a predicted value for Y a 5Y 2 bX b 5 Sxy/Sx2 in which a 5 intercept constant b 5 regression coefficient Y 5 mean of variable Y X 5 mean of variable X x 5 deviation score for X (the difference between an individual score and the mean) y 5 deviation score for Y The graph of the linear regression equation is a straight line that “best fits” the data.192  CHAPTER 6 Mathematical Procedures y 5 deviation score for Y Sxy 5 sum of the products of each pair of deviation scores n 5 number of Xvalues paired with a Yvalue sx 5 standard deviation of X scores sy 5 standard deviation of Y scores Linear Regression (Method of Least Squares) Once a correlation has been found between two variables. . The higher the correlation between the two variables. it is often useful to find an equation relating them such that one variable (X) can be used to predict the second (Y).
Thus. The word percentile is often used to refer directly to a score in a distribution. percentile rank of X 5 where B 5 the number of scores below the given score X E 5 the number of scores equal to the given score X n 5 the total number of scores B 1 1>2 E n 3 100 . –3σ –2σ –σ μ 68% 95% 99. bellshaped curve illustrating the ideal or equal distribution of continuously variable values about a population mean (see Figure 6–3). Percentile Rank The percentile rank of a score essentially gives the percentage of the distribution that is below that score.7% +σ +2σ +3σ Figure 63 Standard deviations (s) in a normal curve. A standard normal distribution has a mean of zero and a standard deviation of one.Statistical Procedures  193 Normal Distribution Curve The normal distribution curve is a symmetric. a score with a percentile rank of 60 would be in the 60th percentile.
Type I error. it is the probability of an observed statistical value being equal to or greater than a given value. the probable value or P value of the test is the smallest value of a that results in the rejection of the null hypothesis. The group of experimental units from which a sample is selected. It is the probability of incorrectly rejecting the null hypothesis (Type I error). For example.e. Type II error. hence the P value of the observed statistic is 0. Given a test procedure and the computed value of the test statistic. A subset of a population. A variable describing some characteristic of a population. Beta (b). Population. Statistic.194  CHAPTER 6 Mathematical Procedures Definitions of Common Statistical Terms Alpha (a. The power of a statistical test is the probability of correctly rejecting the null hypothesis. The probability of incorrectly accepting the null hypothesis (Type II error).046. power is equal to 1 – b. An entire collection of objects as defined by a set of criteria. level of significance).. Research hypothesis. A “null hypothesis” usually states that there is no difference between or among two or more populations for a given parameter. An “alternate hypothesis” usually states that there is a difference between or among two or more populations for a given parameter. Variable. Accepting the null hypothesis on the basis of a statistical test when it is actually false. that the sample came from a population whose mean value was the proposed value) is 0. Universe. . A variable describing some characteristic of a sample and used to infer the same characteristic of the corresponding population. Numerically. A statement about the parameters of a population. Sample. A numerical quantity that can take on different values. the smallest value of a that results in rejection of the null hypothesis (i.046.046. the probability of observing a sample mean that is equal to or greater than two standard deviations away from the proposed population mean is 0. Rejecting the null hypothesis on the basis of a statistical test when it is actually true. Thus. Stated differently. P value. Power. Parameter. The preselected level of probability that leads to rejection of the null hypothesis.
Condition of Interest b Present a Absent Positive True Positive False Positive Test Result c d Negative False Negative True Negative Sensitivity: Specificity: a a+c d b+d False negative rate: False positive rate: Positive predictive value: b a+b c c+d a a+b d c+d Negative predictive value: Figure 6–5 Definitions of sensitivity. and related indices. specificity. 195 .Reality Null hypothesis is true (nonsignificant result) Null hypothesis is false Do not reject null hypothesis Statistical Test Result Correct decision probability = 1 – α Type II error probability = β Reject null hypothesis (significant result) Type I error probability = α Correct decision probability = 1 – β Figure 6–4 Definitions and probabilities of Type I and Type II errors.
g. ... + an The average value of x The change in x The derivative of x with respect to time Product of. The probability that a test will be negative when the condition of interest (e. . . an . 2) Is proportional to The sum of.g. SaK means a1 + a2 + . The probability that the condition of interest (e. The falsenegatives as a percentage of all negative results. Truepositive rate.196  CHAPTER 6 Mathematical Procedures Sensitivity. Equivalent to specificity. r S x Dx # x P Equals Equals approximately Is not equal to Is identical to. $ # . Truenegative rate. The probability that the condition interest (e. disease) is present. Falsenegative rate..g. .. Negative predictive value. disease) is not present. disease) is not present when the test is negative. PaK means a1 a2 . The falsepositives as a percentage of all positive results. Specificity. is defined as Is greater than (@ is much greater than) Is less than (! is much less than) Is greater than or equal to (or is no less than) Is less than or equal to (or is no more than) Plus or minus ( 24 5 . disease) is present when the test is positive.g. . Positive predictive value. . Equivalent to sensitivity. Falsepositive rate. The probability that a test will be positive when the condition of interest (e. ■■ mathematical signs and symbols Table 6–3 5 < ? .
Random Numbers  197 ■■ the greek alPhabet Table 6–4 Alpha Beta Gamma Delta Epsilon Zeta Eta Theta Iota Kappa Lambda Mu Nu Xi Omicron Pi Rho Sigma Tau Upsilon Phi Chi Psi Omega A B G D E Z H Q I K L M a b g d e z h u i k l m N J O P R S T Y F X C V n j o p r s t y w x c v ■■ random numbers A table of random numbers (Table 6–5) can be used to select a random sample of N items from a universe of M items using the following procedure: Table 6–5 Random Numbers 10480 15011 22368 46573 24130 48360 42167 93093 37570 39975 77921 99562 96301 89579 85475 06907 72905 91977 14342 36857 01536 25595 22527 06243 81837 11008 56420 05463 63661 43342 02011 85393 97265 61680 16656 42751 69994 07972 10281 53988 81647 30995 76393 07856 06121 27756 98872 18876 17453 53060 91646 89189 64809 16376 91782 53498 31016 20922 18103 59533 (continued) .
it is skipped and the next desirable number is taken. the items would be numbered from 001 to 250 such that each item is associated with a threedigit number. and last digits would yield the number 140. Take the fraction portion (FRAC. the numbers to the right of the decimal point) as the random number. 10480. This process is continued until the random sample of N items is selected. and fifth digits in the entry to create the required threedigit number corresponding to an item in the universe. 3. The procedure for using the equation is as follows: 1. xn. If a number . If the number formed in step 3 is #M. if the first selection was the first entry in the first column of Table 6–5. the first. third. Thus. Thus.198  CHAPTER 6 Mathematical Procedures Table 6–5 Random Numbers (continued) 28918 69578 88231 63553 40961 48235 09429 93969 52636 10365 61129 87529 07119 97336 71048 33276 03427 92737 85689 08178 70997 49626 88974 48237 77233 79936 69445 33488 52267 13916 1. 4. Assign numbers to each of the items in the universe from 1 to M. Select a number between 0 and 1 and add it to the value of p. Thus. each entry has five digits and for this example we need only three. third. Raise the result to the fifth power. That is. 3. use the entries from the first line of each column. For example. A widely used equation for generating random numbers is xn11 5 FRAC (p + xn)5 The equation requires a seed number. 2. 2.M is formed in step 3 or is a repeated number of one already chosen. Create an arbitrary procedure for selecting entries from the table. we might decide to use the first. . then the correspondingly designated item (from step 2) in the universe is selected for the random sample of N items. For example. which can be varied between 0 and 1 to give many random number sequences. Decide on an arbitrary scheme for selecting digits from each entry in the table selected according to step 1. item number 140 of the universe of items would be the first picked for the sample. if M 5 250.
The definitions of the base units are listed in the next section. and 6–11 contain further information on units of measurement. It is a system of reporting numerical values that promotes the interchangeability of information between nations and between disciplines. Tables 6–8. 6–10. ■■ si units* “SI units” stands for le Système international d’Unités. the radian for the plane angle and the steradian for the solid angle. There are two supplemental units. 6–9.SI Units  199 4. Use the fraction portion of the answer as the new value of x. It consists of seven base units (Table 6–6) from which other units are derived (Table 6–7). . Table 6–6 Base Units of SI Physical Quantity Length Mass Time Amount of substance Thermodynamic temperature Electric current Luminous intensity Table 6–7 Representative Derived Units Derived Unit Name (Symbol) Area Square meter Volume Cubic meter Force Newton (N) Pressure Pascal (Pa) Work. energy Joule (J) Mass density Kilogram/cubic meter Frequency Hertz (Hz) Base Unit Meter Kilogram Second Mole Kelvin Ampere Candela SI Symbol m kg s mol K A cd Derivation From Base Units m2 m3 kg ? m ? s22 kg ? m21 ? s22 (N/m2) kg ? m2 ? s22 (N ? m) kg/m3 s21 *Portions of this section are reprinted with permission from Respir Care 33 1988:861–873. Repeat the procedure until the required number of random numbers is generated. or International System of Units. 5.
Table 6–9 SI Style Specifications Specifications Use lowercase for symbols or abbreviations. Kilograms kgs kg (continued) . they are written in plain rather than boldface type.200  CHAPTER 6 Mathematical Procedures Table 6–8 Prefixes and Symbols for Decimal Multiples and Submultiples Factor Prefix Symbol exa E 1018 peta P 1015 tera T 1012 giga G 109 mega M 106 kilo k 103 2 hecto h 10 deka da 101 deci d 1021 22 centi c 10 milli m 1023 m micro 1026 1029 10212 10215 10218 nano pico femto atto n p f a Factors in bold do not conform to the preferred incremental changes of 103 and 1023 but are still used outside medicine. Incorrect Style kg K A L m Correct Style Symbols are not followed by a period except at the end of a sentence. Do not pluralize symbols. Note that in use. Exceptions: Example Kilogram Kelvin Ampere Liter Meter Kg k a l m.
500.000 Correct Style kg ? m ? s22 100 m 2 mol 50 mL kg ? m ? s22 mmol/(L ? s) 0.000 1. Decimal numbers are preferable to fractions and percents.75 0.SI Units  201 Table 6–9 SI Style Specifications (continued) Specifications Example Names and symbols are not to be combined. The product of units is indicated by a dot above the line.01 3/4 75% 1.01 0. Use a space between the number and symbol. symbols are preferred.75 1 500 000 1000 or 1 000 Table 6–10 Currently Accepted NonSI Units Quantity Name Symbol Value in SI Units Time Minute min 1 min 5 60 s Hour h 1 h 5 60 min 5 3 600 s Day d 1 d 5 24 h 5 86 400 s 8 Plane angle Degree 18 5 (p/180) rad 9 Minute 19 5 (1/60)8 5 (p/10 800) rad 0 Second 10 5 (1/60)9 5 (p/648 000) rad Volume Liter L 1 L 5 1 dm3 5 1023 m3 Mass Ton (metric) t 1 t 5 103 kg Area Hectare ha 1 ha 5 1 hm2 5 104 m2 . Force Incorrect Style kilogram ? meter ? s22 100 meters 2 moles 50mL kg 3 m/s2 mmol/L/s . When numbers are printed. Spaces are used to separate long numbers (optional for fourdigit number). Use only one virgule (/) per expression. Place a zero before the decimal.
807 Pound S kilogram0.20 Compliance L/cm H2O (continued) .09290 Volume dL (5 100 mL) L 0.185 Kilocalorie (C) J 4185 British thermal unit 1055 (BTU) Surface tension dyn/cm N/m 0.3 Millibar (mbar) kPa 0.01 m3 0.001 L/kPa 10.2 ft2 m2 0.4536 force Ounce S gramforce 28.57 mg/dL mmol/L 10/mol wt Amount of substance mEq/L mmol/L valence mL of gas at STPD mmol 0.3048 m2 6.02832 ft3 3 L 28.) meter (m) 0.895 Pounds/in.35 kilopascal (kPa) 0.00001 Kilogramforce N 9.09806 Pressure cm H2O mm Hg (torr) kPa 0.736 cm H2O S torr Standard atmosphere kPa 101.1000 Work. energy Calorie (c) joule (J) 4.04462 Force Pound (lb) newton (N) 4.31 psi S cm H2O 0.1333 kPa 6.0254 Foot (ft) m 0.448 Dyne N 0.202  CHAPTER 6 Mathematical Procedures Table 6–11 Conversion Factors for Units Commonly Used in Medicine Physical Quantity Conventional Unit SI Unit Conversion Factor* Length Inch (in.32 ft Fluid ounce S mL 29.2 (psi) 70.452 3 1024 Area in.
“The luminous intensity. “Equal to the mass of the international prototype of the kilogram (held at Sevres). if maintained in two straight parallel conductors of infinite length. water.73 wavelengths in vacuum of the radiation corresponding to the transition between the levels 2p10 and 5d5 of the krypton86 atom. “That constant current which.15 8F S 8C 8C 5 (°F 2 32)/1. in the perpendicular direction.6 newton/m2. and vapor coexist in equilibrium at a temperature of +0.Definitions of Basic Units  203 Table 6–11 Conversion Factors for Units Commonly Used in Medicine (continued) Physical Quantity Conventional Unit SI Unit Conversion Factor* Resistance kPa ? s ? L21 0. 1901) Meter.998 mm Hg ? min ? L mmol ? s21 ? 0. ■■ deFinitions oF basic units Ampere. 1967) The triple point of water is the temperature at which ice.16 of the temperature of the triple point of water.8 8C S 8F 8F 5 (1. To convert in the opposite direction. 1967) Kelvin.04462 Temperature 8C K K 5 8C + 273. multiply conventional unit by conversion factor.00758C and a pressure of 610.” (3rd CPGM. would produce between these conductors a force equal to 2 3 1027 newton per meter of length. 1 L 5 1 L/0.09806 airway cm H2O ? s ? L21 25 kPa ? s ? L21 0.133 3 kPa 5 1.” (13th CPGM. Examples: 10 torr 5 10 3 0.333 kPa.1000 vascular dyn ? s ? cm 21 21 kPa ? s ? L 7.” (13th CPGM. 1948) Candela. “Equal to 1 650 763. 1960) * CPGM stands for General Conference of Weights and Measures.” (11th CPGM*.” (CPGM. divide by conversion factor. Kilogram. of a substance of 1/600 000 square meter of black body at the temperature of freezing platinum under a pressure of 101 325 newton per square meter.10 5 10 dL. . “The fraction of 1/273.4550 Gas diffusion mL ? s21 ? cm H2O21 kPa21 Gas transport mL/min mmol/min 0.8 ? 8C) + 32 * To convert from conventional to SI unit.
Nunn. electrons. Volume (dimensions: length3). the elementary entities must be specified and may be atoms. the cubic decimeter (dm3). defined as the angle subtended at the center of a circle by an arc whose length is equal to the radius of the circle. ■■ Physical Quantities in resPiratory Physiology The dimensions of the physical quantities described here are in mass/length/ time units. The cubic centimeter (cm3) or milliliter (mL) may still be used as a volume unit other than as the denominator of a concentration unit. minutes.” (13th CPGM. number of molecules) of gas exchanged . molecules. 1978): It is not good practice to report gas volumes under the conditions prevailing during their measurement.012 kilogram of carbon 12. 2nd ed. Radian. There are 4 ? p steradians in a sphere. The unit of measure for plane angles. has been accepted as the reference volume for stating concentrations. or specified groups of such particles. ions.” (14th CGPM. “The amount of substance of a system which contains as many elementary entities as there are atoms in 0. “The duration of 9 192 631 770 periods of the radiation corresponding to the transition between the two hyperfine levels of the ground state of the cesium133 atom. That is.. According to J. In the case of oxygen uptake. Since the circumference of a circle is equal to 2 ? p radius of circle.204  CHAPTER 6 Mathematical Procedures Mole. carbon dioxide output and the exchange of “inert” gases. and is also more practical for use with computers. and only identical mass/length/time units can be added or subtracted. 1971) When the mole is used. In general. Second. Applied Respiratory Physiology. we need to know the actual quantity (i. F. The analogous unit of (radian) measure for solid angles. given the name liter. angle (radians) 5 arc length/radius. (London: Butterworths. a revolution of 3608 equals 2 ? p radians. other particles. the same mass/length/time units must be on both sides of an equation. These units provide a way of checking the validity of equations and other expressions used in the study of respiratory physiology.e. 1967) Steradian. Although the cubic meter (m3) is the SI base unit for volume. Radian measure is much easier to work with than degrees. and seconds.
(pp.8 mg/dL. which is conventionally reported as 8.. Equivalent weights (e. 445–452) Standard conditions are 273. milliequivalents) are related to molar concentrations by their ionic valence. In applying this to clinical practice. and dry (STPD).) Because water is not thought of as a chemically active substance for the purposes of humidification.00 mmol/L. First we convert to mg/L: (8. mmol/L).00 mmol/L) 3 (2 mEq/1 mmol) 5 2. Amount of substance (dimensionless). Converting the other way. the sum of the concentrations of ideal gases in a mixture would be 44. . we start with a normal value for calcium.8 mg/dL) 3 10 dL/L) 5 88 mg/L.g.6 mmol/L. 40.4 L at STPD. equivalent weight equals mole/valence.08 g) divided by 2 (the valence) or 20. body. the unit may be grams per liter (g/L).00 mEq/L) 3 (1 mmol/2 mEq) 5 1. saturated (BTPS). To convert to mmol/L.. they should be expressed as they would be at body temperature and pressure. for example.02 equivalents. The concentration of chemical substances is reported primarily in moles per liter (mol/L) or some multiple thereof (e.g. mg/L).08 mg) 5 2. (1.Physical Quantities in Respiratory Physiology  205 and this is most conveniently expressed by stating the gas volume as it would be under standard conditions .20 mmol/L.00 mEq/L. We are generally interested in flow into and out of the airways and how this changes lung volume.15K (08C). we convert to mmol/L: (88 mg/L) 3 (1 mmol/40. Volume flow rate is a special case of mass flow rate. Serum ionized calcium (Ca2+) is reported as milliequivalents per liter (mEq/L). (Note that 1 mg/mL 5 1 g/L 5 1 kg/m3. Next. That is. Conversions between ambient.00 mEq/L. 1 mole occupies 22. (2. We therefore speak of . When the molecular weight of a substance is not known. When volumes relate to anatomic measurements such as tidal volume or vital capacity. and bicarbonate.e.3 kPa (760 torr) pressure. Example Thus. Volume flow rate (dimensions: length3 ? time21). potassium. one equivalent weight of serum calcium is 1 mole (1 gram molecular weight. For ideal gases such as oxygen and nitrogen. Suppose a value for ionized calcium is reported as 2. Therefore. 101.. and standard conditions are made using tables or equations. it would appear that absolute humidity should still be reported in terms of weight instead of moles (i. mEq/L and mmol/L are numerically equal. For univalent ions such as sodium. chloride. .
In the British system. Therefore. the kilogramforce is being retained as the standard unit to express weight for medical purposes. the kilogramforce is a poor unit for standardization.e. flow measurements require accurate temperature and pressure measurements to be accurate. Hence. a force of 1 pound is produced when a mass of 1 slug is accelerated at the rate of 1 foot per second per second.8 m/s2 or 32 ft/s2) . The problem with this convention. with a spring scale. What is implied is that a mass of 1 gram (or kilogram) experiences a force due to standard conditions of gravity (9. determined. is that the force of gravity varies from point to point on Earth. to say that 10 kilograms “equals” 22 pounds means that the 10kilogram mass experiences a force of 22 pounds under standard conditions of gravity (i. Thus. Thus. When we speak of a volume flow of so many liters per minute. and milliliters per minute (mL/min) are acceptable at present. volumes do not.. gas volumes at STPD are about 10% less than at ATPS. the weight would be zero. for example. As a rule of thumb. At the present time. Force (dimensions: mass ? length ? time22). they are used as such and sometimes referred to as gramforce or kilogramforce. Although these units are not units of force (i. 0. Therefore. for example. .206  CHAPTER 6 Mathematical Procedures volume as if it flows—flows are expressed in liters per minute. is defined as the force that will give a mass of 1 kilogram an acceleration of 1 meter per second squared (kg ? m ? s22). aside from the fact that it is confusing.e. will vary depending on where on Earth it is measured. This shorthand notation overlooks an important physical fact: Gases flow. Units of liters per minute (L/min). One type of force that is in common usage is that due to gravity acting on a standard mass. weights are often expressed in grams or kilograms. This is the basis for converting pounds to kilograms and vice versa. Gas exchange rates should be corrected to STPD. the weight of 1kilogram mass. liters per second (L/s).6852 slug ? 32 ft ? s22).e.. Force is defined as mass times acceleration. This force is interpreted as weight (i. what we are really saying is that the mass of gas that has exited from the lung over that time would occupy a volume of so many liters at some specific temperature and pressure. weight equals mass times acceleration due to gravity). for instance. while ventilatory gas flow rates should be corrected to BTPS. In space. the newton (N). or “one unit” of acceleration.. In the metric system. the weight of a 1kg mass is 1 N). while volumes at BTPS are about 10% more. The SI unit of force. 1 gramforce equals 1 gram mass times 1 unit of acceleration. where gravity is nil.
Power (dimensions: mass ? length2 ? time23). Thus. In respiratory physiology. Work is done when a force moves a body a given distance. The erg and calorie will no longer be used. Power is defined as the rate of change of work. In SI units. is defined as 1 newton per square meter (1 N/m2). Thus.3 kPa. One kPa is approximately 10 centimeters of water (cm H2O). Currently. According to the work–energy theorem. The SI unit of force. however.. This unit provides a convenient link with electrical units because 1 watt equals 1 ampere times 1 volt. However. the work done on a body by an applied force is equal to the change in kinetic energy of the body. A standard atmosphere is 101.Physical Quantities in Respiratory Physiology  207 Pressure (dimensions: mass ? length21 ? time22).. the unit of work is the joule (J). the pascal is inconveniently small (equivalent to about l/10. surface tension would be expressed as the newton per meter. Surface tension is defined as a force per unit length existing at a liquid surface. so the kilopascal (kPa) has been proposed for general use in medicine. It appears that mm Hg may be retained indefinitely for reporting blood pressure. and the partial pressure of oxygen in dry air is approximately 21 kPa. useful work may be recovered. or when gas is moved in response to a pressure gradient. the pascal (Pa). it reflects a change in energy of the system. or when a liter of gas moves in response to a pressure gradient of 1 kilopascal (i. which is equal to 1 Pa ? m or 1 kg ? s22. pressure can be interpreted as energy density (energy per unit volume).e. The SI unit is the watt (W). In the SI. .000th of an atmosphere). This is the principle used by air rifles and ventilators powered by compressed gas. 1 N ? m). The unit for surface tension is likely to be called the pascalmeter. 1 L ? kPa). meaning that some outside agency has done work on it. defined as force per unit area. When the pressure is released. Work and energy (dimensions: mass ? length2 ? time22). One millipascalmeter is equal to the conventional centimetergramsecond unit (CGS) the dyne/centimeter (dyn/cm). Because pressure times volume yields dimensions of energy. medical journals are still using these units. Surface tension (dimensions: mass ? time22). force is generally expressed as pressure. The millimeter of mercury (mm Hg) and the centimeter of water are two gravitybased units used in medicine that will eventually be replaced for reporting gas pressures. defined as the work done when a force of 1 newton moves a body a distance of 1 meter (i.e. defined as 1 joule per second. if the pressure of a system increases. a kilopascal is about 1% of an atmosphere.
Although the SI unit for temperature is the kelvin (K). In SI units. For solutions with a nonlinear dissociation curve (e. Solubility (dimensions: time ? length21).. conductance. the slope of the pressurevolume curve). The solubility of a gas in liquid has been expressed in many different units. The appropriate SI units are kPa ? L21 ? s. it has an absolute zero that makes possible statements like. the slope of the flowpressure curve). the capacitance coefficient would be defined between two points (arterial and venous) as difference in concentration (mmol ? L1) divided by difference in partial pressure (kPa). The reciprocal.e. Resistance to laminar flow is defined as the change in the pressure difference causing flow divided by the associated change in flow rate (i.e. which has been given the name capacitance coefficient. Temperatures expressed in degrees kelvin and Celsius both have the samesized increments. This is simplified in SI units as mmol ? L1 ? kPa21. Compliance is defined as the change in the volume of a system divided by the corresponding change in the pressure difference across the walls of the system (i. Thus. The reciprocal.. This coefficient varies only with temperature when a solution obeys Henry’s law.” . elastance.208  CHAPTER 6 Mathematical Procedures Compliance (dimensions: mass ? length24 ? time22).g. but the kelvin scale offers the advantage of being a ratio rather than an interval scale. oxygen in blood). some medical journals still use the Celsius scale. has units of kilopascal per liter.. “The temperature in group A was 5% higher than group B. compliance would be expressed as liter per kilopascal (L/kPa). Temperature. has units of kPa21 ? L ? s21. Resistance (dimensions: mass ? length24 ? time21).
APPENDIX Reference Data .
lib. AG Ant. Ad. ante Aq. bid bpm c cc CI comp CO DC dL dr g gtt kg mg mEq mg mL of each before meals as desired anion gap anterior before water twice daily beats per minute with cubic centimeters cardiac index compound cardiac output discontinue deciliter (= 100 mL) dram gram drop kilogram microgram milliequivalent milligram milliliter nmol p PEEP PIP PO PR prn pt q qd qh q2h qhs qid qt s SI sol stat STP tid vol% nanomole after positive endexpiratory pressure peak inspiratory pressure by mouth rectal as needed pint every every day every hour every two hours at bedtime four times a day quart without stroke index solution immediately standard temperature and pressure three times daily volume percent .c.210  Appendix Reference Data ■■ CliniCal abbreviations aa a.
. Xa = XA. it equals D ? (Pb 2 PH2O)/Va Dm Diffusing capacity of the alveolar capillary membrane (STPD) . e. concentration c Capillary c9 Pulmonary end capillary C/Vl Specific compliance CD Cumulative inhalation dose. The total dose of an agent inhaled during bronchial challenge testing.Physiological Abbreviations  211 ■■ PhysiologiCal abbreviations The terminology and abbreviations listed here are those suggested by the American College of Chest Physicians and the American Thoracic Society Joint Committee. When small capital letters are not available. compliance determined from measurements made during conditions of prolonged interruption of airflow D/Va Diffusion per unit of alveolar volume Dk Diffusion coefficient or permeability constant as described by Krogh. saturated with water vapor at these conditions b Barometric (qualifying symbol) BTPS Body conditions: body temperature. and saturated with water vapor at these conditions C A general symbol for compliance.g. e. volume change per unit of applied pressure. Cdyn 40. dry ATPS Ambient temperature and pressure. Cst Static compliance.g.. ambient pressure. it is the sum of the products of concentration multiplied by the number of breaths at that concentration. large capital letters may be used as subscripts. ATPD Ambient temperature and pressure. Cdyn Dynamic compliance: compliance measured at point of zero gas flow at the mouth during active breathing. The respiratory frequency should be designated. Xa or Xa A small capital letter or lowercase letter on the same line following a primary symbol is a qualifier to further define the primary symbol.
expressed as a percentage . FET95% is the time required to deliver the first 95% of the FVC and FET25%–75% is the time required to deliver the FEF25%–75% FEV Forced expiratory volume FEV/FVC% Forced expiratory volume (timed) to forced vital capacity ratio.g. i. D is Dco. FETx The forced expiratory time for a specified portion of the FVC..) e Expired (qualifying symbol) ERV Expiratory reserve volume. A modifier can be used to designate the technique. the maximum volume of air exhaled from the endexpiratory level est Estimated f Ventilator frequency fb Breathing frequency F Fractional concentration of a gas FEFmax The maximum forced expiratory flow achieved during the FVC FEF25%–75% Mean forced expiratory flow during the middle half of the FVC (formerly called the maximum midexpiratory flow rate) FEF75% Instantaneous forced expiratory flow after 75% of the FVC has been exhaled FEF200–1200 Mean forced expiratory flow between 200 mL and 1200 mL of the FVC (formerly called the maximum expiratory flow rate) FEFx Forced expiratory flow. e. Dsb is singlebreath carbon monoxide diffusing capacity and Dss is steadystate carbon monoxide diffusing capacity. DLco) Diffusing capacity of the lung expressed as volume (STPD) of gas (x) uptake per unit alveolar capillary pressure difference for the gas used. e.. Dlcosb.e. and Dlcoss are still the most commonly used abbreviations..g. Dlco. Modifiers refer to the amount of the FVC already exhaled when the measurement is made.. carbon monoxide is assumed to be the test gas.g. (Author’s note: This recommendation has not been widely accepted.212  Appendix Reference Data Dx (e. related to some portion of the FVC curve. Unless otherwise stated.
Physiological Abbreviations  213 FIFx Forced inspiratory flow. the appropriate modifiers must be used to designate the volume at which flow is being measured. Functional residual capacity. an unrestricted frequency is assumed. If no qualifier is given. The volume of air expired in a specified period during repetitive maximum respiratory effort. the dose of an agent used in bronchial challenge testing that results in a defined change in a specific physiologic parameter. The respiratory frequency is indicated by a numerical qualifier. The method of measurement should be indicated. Unless otherwise specified. The parameter tested and the percent change in this parameter is expressed in cumulative FRC FVC Gaw Gaw/Vl i IRV IC l max MIP MEP MVVx OI p P PA Paw PD . the reciprocal of Raw Specific conductance. the sum of RV and ERV (the volume of air remaining in the lungs at the endexpiratory position). MVV60 is MW performed at 60 breaths per minute. the volume qualifiers indicate the volume inspired from RV at the point of the measurement.g. blood or gas Pulmonary artery Airway pressure Provocative dose. e. Forced vital capacity Airway conductance. Oxygenation index Physiologic Pressure. the maximum volume of air inhaled from the endinspiratory level Inspiratory capacity. expressed per liter of lung volume at which G is measured (also referred to as sGaw) Inspired (qualifying symbol) Inspiratory reserve volume. As in the case of the FEF. the sum of IRV and Vt Lung (qualifying symbol) Maximum Maximum inspiratory pressure Maximum expiratory pressure Maximum voluntary ventilation.. as with RV.
and dry (0 water vapor) Time (qualifying symbol) Tidal Thoracic gas volume. PD35sGaw = x units/y minutes. where x is the cumulative inhalation dose and y the time at which a 35% fall in sGaw was noted. a test in which plots of expired nitrogen concentration versus expired volume after inspiration of 100% oxygen are recorded. measured under conditions of maximum expiratory flow Residual volume.g. Airway resistance Rebreathing Respiratory quotient Resistance of the airways on the alveolar side (upstream) of the point in the airways where intraluminal pressure equals intrapleural pressure. The closing volume and slope of phase III are two parameters measured by this test. Standard conditions: temperature 08C. e. the volume of gas within the thoracic cage as measured by body plethysmography PEF pred Pst Q Qc Raw rb RQ Rus RV SBN STPD t t TGV . When determined from the following equation. Peak expiratory flow: the highest forced expiratory flow measured with a peak flowmeter Predicted Static transpulmonary pressure at a specified lung volume. Qc represents the effective pulmonary capillary blood volume. PstTLC is static recoil pressure measured at TLC (maximal recoil pressure) Volume of blood Capillary blood volume (usually expressed as Vc in the literature.214  Appendix Reference Data dose units over the time following exposure that the positive response occurred. The method of measurement should be indicated in the test or. by appropriate qualifying symbols. a symbol inconsistent with those recommended for blood volumes). that volume of air remaining in the lungs after maximum exhalation. that is. Singlebreath nitrogen test. when necessary.. capillary blood volume in intimate association with alveolar gas: I/D = I/Dm + I/(U ? Qc). For example. pressure 760 mm Hg.
as with RV.0 L. [Author’s note: It is still common to find reports in which modifiers refer to the amount of VC remaining. related to the total lung capacity or the actual volume of the lung at which the measurement is made. Venous Mixed venous Ventilation per minute of the physiologic dead space (wasted ventilation).] Tidal volume. BTPS. # Vmax 75% is instantaneous forced expiratory flow when # the lung is at 75% of its TLC. For example. the sum of all volume compartments or the volume of air in the lungs after maximal inspiration. defined by the following equation: # # VD 5 VE 1PaCO2 2 PECO2>1PaCO2 2 PICO22 # The physiologic deadspace volume defined as VD> f Volume of the anatomic dead space (BTPS) Alveolar ventilation per minute (BTPS) Carbon dioxide production per minute (STPD) Expired volume per minute (BTPS) Inspired volume per minute (BTPS) Volume of isoflow.0 is instantaneous forced expiratory flow when the lung volume is 3. TV is also commonly used V v v # VA # VCO2 # VD Vd Vdan # VE # VI # VisoV # VO 2 # Vmax X Vt . water vapor conditions. Vmax 3. and other special conditions must be specified in text or indicated by appropriate qualifying symbols.Physiological Abbreviations  215 TLC Total lung capacity. Modifiers (X) refer to the amount of the lung volume remaining when the measurement is made. the volume when the expiratory flow rates become identical when flowvolume loops performed after breathing room air and helium–oxygen mixtures are compared Oxygen consumption per minute (STPD) Forced expiratory flow. The method of measurement should be indicated. The particular gas as well as its pressure. Gas volume.
Sao2 Arterial oxygen saturation of hemoglobin # QS Physiologic shunt flow (total venous admixture) as a fraction of # total blood flow (QT ) defined by the following equation when gas and blood data are collected during ambient air breathing: # Cc¿ O2 2 CaO2 QS 5 ? QT Cc¿ O2 2 CvO2 Peto2 Po2 of endtidal expired gas FCo2 Fractional concentration of oxygen R A general symbol for resistance. is not recommended.216  Appendix Reference Data ■■ bloodgas MeasureMents Abbreviations for these values are readily composed by combining the general symbols recommended earlier. the previously used symbol. pressure per unit flow Re Respiratory exchange ratio REE Resting energy expenditure S Saturation in the blood phase sat Saturated sGaw Specific airway conductance So2 Oxygen saturation T Temperature TCT Total cycle time Te Expiratory time Ti Inspiratory time VC Vital capacity . A–aDO2. The following are examples: Paco2 Arterial carbon dioxide tension Po2 Partial pressure of oxygen Fio2 Fraction of inspired air Pa Alveolar pressure Va Alveolar volume C(a–v)o2 Arteriovenous oxygen content difference Cc9o2 Oxygen content of pulmonary end capillary blood Feco Fractional concentration of carbon dioxide in expired gas P(a–a)o2 Alveolar–arterial oxygen pressure difference.
Molar solution: 1 mole of solute per liter of solution. The equivalent weight of a substance is calculated by the equation: gram molecular weight Equivalent weight 5 valence Milliequivalent (mEq): onethousandth of an equivalent weight.000 grams of solvent. or ions of two or more different substances.” which is used to designate a solution that is isotonic with human body fluid. Isotonic solutions: solutions having equal osmotic pressure. Osmolar solution: 1 osmole per liter of solution. One gram equivalent weight of any electrolyte has the same chemical combining power as 1 gram of hydrogen. The gram molecular weight (formula weight) is the weight of a mole of the substance. Gram molecular weight: the atomic weight of a compound expressed in grams. The osmolality of extracellular fluid can be calculated according to the formula glucose 1mg>dL2 serum osmolality 1mOsm>kg2 5 2 3 Na 1mEq>L2 1 18 1 1 BUN 1mg>dL2 2.9% solution of sodium chloride or 9 g per 1. Buffer solutions: aqueous solution able to resist changes of pH with addition of acid or base. Normal saline is a 0. Molal solution: 1 mole of solute per 1. Equivalent weight: the weight of a substance that either receives or donates 1 mole of electrons. Osmole solution: molarity 3 number of particles per molecule. Solvent: the dissolving medium in a solution. or solid) in a solution.Basic Pharmacological Formulas and Definitions  217 ■■ basiC PharMaCologiCal ForMulas and deFinitions Solutions: Definitions and Terms Solution: a homogeneous mixture (usually liquid) of the molecules. This should not be confused with the term “normal saline.2 1 isopropanolol 1mg>dL2 6 .000 mL. atoms. Normal solution: 1 gram equivalent weight of solute per liter of solution.6 1 ethylene glycol 1mg>dL2 6.8 3.2 methanol 1mg>dL2 1 ETOH 1mg>dL2 4. liquid. Solute: the dissolved substance (which may be a gas.
You only have tablets of 0.4 mg Amount supplied = 1 tablet Prescribed dosage = 0.4 5 3 tablets.4x 5 1. How many tablets do you give the patient? Original drug strength = 0. Example Your patient is going to surgery. .2 mg Amount to be given = x Using the above formula.02 mg/kg of atropine preoperatively.4 mg 1. Amount supplied Unknown amount to be supplied 3.02 mg/kg 3 60 kg = 1.2 x 5 1. or Capsules 1. Calculate the dosage. Volume to volume: the number of milliliters of active ingredient in 100 mL of a mixture. She weighs 60 kg. Set up the following proportion: Prescribed dosage Original drug strength 5 . 2. Convert all measurements to the same unit.2>0. Calculating Dosages from PercentStrength Solutions Types of Percentage Preparations Weight to weight: the number of grams of active ingredient in 100 g of a mixture. Weight to volume: the number of grams of active ingredient in 100 mL of a mixture. Tablets.2 mg 5 1 tablet x tablets 0. we get 0.218  Appendix Reference Data Drug Dosage Calculation Calculating Dosages from Stock Solutions.4 mg/tablet strength. and the physician ordered 0.
05 1 1:100 0.0 mL of saline? Answer A 1:200 solution contains 5 mg of drug per mL. Thus. although usually milliliters is assumed. which is a 1:6 volume to volume ratio).5 mL isoproterenol + 3. the “ratio by simple parts” prescription still persists. A 0.0% solution contains 1.5 mL 3 5 mg/mL = 2. However.0 mL saline. Therefore.1 5 1:20 0.5 mg of drug. When preparing percentage solutions.5 mg of isoproterenol in a total of 3. This is based on the fact that 1. 2.01 0. a physician may order aerosol therapy with a 1:8 solution of isoetharine. For instance. .000 0.1 g in 100 mL. 0.5 mL of solution (0.Basic Pharmacological Formulas and Definitions  219 1. This indicates one part medication to eight parts diluent. this type of prescription does not specify the actual dosage of isoetharine (either volume or weight) or the units.5 mL 1:200 isoproterenol (Isuprel) in 3. Example How much isuprel is delivered in an aerosol composed of 0.1% solution contains 0.5 1:200 0. Calculate the weight strength. the aerosol contains 2.0 g (Table A1).001 * mg/mL 1000 100 50 10 5 1 Weight to volume.0 mL of H2O at STP has a mass of 1.5 ml of a 1:200 (weight to volume) solution contains 0.005 0. Table A–1 Percentage Concentrations of Solutions* Percentages Ratio g/mL 100 1:1 1 10 1:10 0. the following rule applies: A 1. Unfortunately.0 g in 100 mL.1 1:1.
5 grains = 1 ounce 16 ounces = 1 pound 7.06 mL 1 minim Weight Metric Apothecary 1 kilogram (1000 grams) — 500 grams 7680 grains 454 grams 5760 grains 29 grams 480 grains 4 grams 60 grains Household 2 tumblerfuls 3 teacupfuls 2 teacupfuls 2 tablespoonfuls 1 small teaspoonful 1/4 teaspoonful 1 drop Avoirdupois 2.220  Appendix Reference Data ■■ MisCellaneous reFerenCe data Table A–2 Measurement Units The Apothecary System Weight 20 grains = 1 scruple 3 scruples = 1 dram 8 drams = 1 ounce 12 ounces = 1 pound Volume 60 minims = 1 fluid dram 8 fluid drams = 1 fluid ounce 16 fluid ounces = 1 pint 2 pints = 1 quart 4 quarts = 1 gallon The Avoirdupois System Weight 437.2 pounds — 1 pound (16 ounces) 1 ounce (437 grains) — .000 grains = 1 pound Table A–3 Approximate Conversion Equivalents Liquid Metric Apothecary 1 liter (1000 mL) 1 quart (2 pints) 500 milliliters (mL) 1 pint (16 fluid ounces) 360 mL 12 fluid ounces (1 pound) 30 mL 1 ounce (8 drams) 4 mL 1 dram (60 minims) 1 mL 16 minims 0.
1 (0) Evaporate or coalesce Table A–5 Physical Factors in Aerosol Deposition Size/Type Factor Particle Site of Deposition Inertial impaction High density . mouth.5 Bronchioles. larynx. acini 1 60 Acini 0. airway bifurcations Sedimentation High density 1–6 Bronchioles. bronchioles 3 8.60% may be exhaled) .1 mm Entire pulmonary tree.0. acini. slow breathing Increased with breathholding . bronchi. larynx.10 100 Pharynx. trachea 5 90–95 Larynx.6 35 Alveoli (.Miscellaneous Reference Data  221 Table A–3 Approximate Conversion Equivalents (continued) Weight Metric Apothecary Avoirdupois 1 gram (1000 mg) 15 grains — 60 milligrams (mg) 1 grain 1 grain 1 mg (1000 micrograms) 1/60 grains — Table A–4 Deposition of Aerosol Particles (Mouth Breathing) Maximum Particle Size Retention (mm) (%) Site of Retention . Nose. phar10 mm ynx. acini (gravity) mm Diffusion . alveoli Remarks Increased with high flow rate Increased with deep.
2 104.0 36 96.0 25 77.4 23 73.6 22 71.6 17 62.0 105. Divide by 1.8 107. Celsius 0 22 37 100 121 To convert Fahrenheit to Celsius: 1.8 32 89.4 111. .6 33 91.6 8C 48 49 50 51 52 53 54 55 56 57 58 8F 118.4 34 93.4 18 64. Body temp. 2.0 114.0 26 78.4 120.2 19 66.8 125.6 127.8 * 8C 37 38 39 40 41 42 43 44 45 46 47 8F 98.4 To convert Celsius to Fahrenheit: 1.0 31 87.8 16 60.6 109.8 134.8 2. Multiply by 1.4 129.8 21 69. Water boils Autoclave temp.6 136.2 24 75.2 35 95.222  Appendix Reference Data Table A–6 Conversion Table for Temperature* 8C 8F 8C 8F 15 59.6 212 250 Water freezes Room temp.4 102.4 29 84.2 30 86.8 27 80.0 123.8 116.2 113.8 Fahrenheit 32 72 98. Add 32.6 28 82.0 20 68.6 100.0 132. Subtract 32.2 131.2 122.
03125 1 quart 946 57.3 1 cc 1.39 1.6 1.8 1.804 1.056 Liters 0.333 1.43 1.00 1 pound (lb) 7000 454 1 kilogram (kg) 15432 1000 Table A–9 Conversion Table for Length Length cm in.0833 1.00 0.00 1000 1609 .002205 1.0100 0.0173 1 in.0338 0.0 33.914 1.394 1 inch 2.54 1.00 1 liter 1000 61.00 1.28 3280 5280 yd 0.00 2.00100 0.0296 0.4 1 kilometer 100.094 1094 1760 m 0.01639 0.01094 0.00 0.554 0.00 3.001057 16. 1 centimeter 1.00 ft 00328 0.0000648 0.903 63.Miscellaneous Reference Data  223 Table A–7 Conversion Table for Volume fl oz Quarts Volume cc In.001000 0.0278 0.00 0.360 lb 0.0001429 0.0254 0.00 1 foot 30.00 0.0648 1 gram (g) 15.0 1.48 12.061 0.454 1.946 1.000 39.0 39.00 0.4 36.0 1 yard 91.400 1 mile 160.0 1 meter 100.75 32.00 Table A–8 Conversion Table for Weight Weight gr g 1 grain (gr) 1.205 kg 0.00 3.305 0.3 1 fl oz 29.
68 Pound/inch (psi) 0.074 1.249 3. .06 133.000 * ** Water at 39.100 0. H2O 1.0 0.000 0.019 14.030 0.039 29. of water to cm H2O.736 1.010 mbar 2.0001 0.28F (48C).010 10. newton/m2 (Pa) Kilopascal (kPa) 4.95 0.001 1.868 25.1 3386 6895 98.72 0. Mercury at 328F (O8C).000 Inch of water* (H2O) 13.0 1.31 1.59 Inch of mercury (Hg)** 2 27.3 0.92 0.001 0.036 0.098 0.014 0.000 0.360 1033 1.401 0.750 0.224  Appendix Reference Data Table A–10 Conversion Table for Pressure Known Value in.394 Centimeter of water (cm H2O) Millimeter of mercury (mm Hg) 0.002 0.540 = 254 cm H2O.333 1013 1.501 atm 0.8 Millibar (mbar) 0.015 in.295 psi 0036 0.000 2.010 10.535 Atmosphere.491 1.014 0.20 mm Hg 1.40 51.3 101325 100.70 0.000 760.145 cm H2O 2. Hg 0.068 0.895 0.008 7.000 0.53 70. multiply 100 by 2.540 34.00 Pa 249.000 1000 kPa 0.0003 0. standard (atm) 406.001 1025 0.029 0.981 1.386 6.000 1.001 1. To convert: Multiply known value by appropriate conversion factor.491 33.020 0.004 Pascal.86 68.033 0.133 101. Example: To convert 100 in.
3 18 4.0 0.7 16 3.3 30 7.3 12 2.184 4.210 5.0 0. . OD = outside diameter.7 34 8.0 0.341 8.7 28 6.0 0.105 2.5 0.Miscellaneous Reference Data  225 Table A–11 Conversion Table for Tubes/Catheters Approximate Outside Diameter (OD)* Millimeters French (ID)* Inches Millimeters 6 1.446 11.079 2 8 1.288 7.5 0.5 0.7 10 2.3 24 5.158 4 14 3.3 *ID = inside diameter.5 0.367 9.7 22 5.5 0.5 0.0 0.131 3.420 10.0 0.0 0.398 10 32 7.5 0.263 6.236 6 20 4.0 0.315 8 26 6.
028 0.006 32 0. Weight.0 1.020 0.6 0.013 24 0.018 0.20 3 mo 21 11.109 0.0 1.025 0.0 0.032 0.05 15 yr 63 110.085 14 0.063 16 0.007 30 0.25 1 yr 31 22.010 28 0.010 26 0.50 Adult 68 154.014 0.022 0.0 0.80 9 yr 53 66.035 0.0 0.226  Appendix Reference Data Table A–12 Conversion Table for Hypodermic Needle Tubing Gauge Inches (OD) Inches (ID) 12 0.023 21 0.0 1.) Weight (lb) BSA (m2) Newborn 20 6.004 Table A–13 Average Body Surface Area (BSA) to Age.0 0.75 .45 3 yr 38 32.047 18 0.62 6 yr 48 46.012 0. and Height Age Height (in.020 22 0.050 0.012 25 0.033 19 0.083 0.016 23 0.065 0.027 20 0.042 0.009 0.
5 wt + 33)/100 General (Dubois) BSA (m2) = wt0.70 18 0. Table A–15 Pediatric Body Surface Area (BSA) Chart Infant Child Weight (kg) BSA (m2) Weight (kg) BSA (m2) 3 0.23 22 0.74 19 0.81 .52 38 1.725 3 0.98 7 0.23 12 0. height in cm.83 4 0.59 15 0.18 11 0.5–20 kg) BSA (m2) = (3.49 36 1.31 30 1.33 14 0.77 20 0.88 5 0.67 17 0.41 32 1.56 40 1.31 26 0.08 9 0.6 wt + 9)/100 Child (20–40 kg) BSA (m2) = (2.63 16 0.20 20 0.Miscellaneous Reference Data  227 Table A–14 Body Surface Area (BSA) Prediction Equations* Infant (2.00781 * Weight in kg.27 24 0.13 10 0.93 6 0.34 28 1.425 3 ht0.03 6 0.45 34 1.28 13 0.
(cm) 49 100 (147) 59 00 (152) 59 20 (157) 59 40 (163) Large Frame lb (kg) 118–131 (54–60) 122–137 (55–62) 128–143 (58–65) 134–151 (61–69) .228  Appendix Reference Data Table A–16 1983 Metropolitan Life Insurance Height and Weight Tables* Men Height Small Frame Medium Frame Large Frame ft in. (cm) lb (kg) lb (kg) lb (kg) 59 20 128–134 131–141 138–150 (157) (58–61) (60–64) (63–68) 59 40 132–138 135–145 142–156 (163) (60–63) (61–66) (65–71) 59 60 136–142 139–151 146–164 (168) (62–65) (63–69) (66–75) 59 80 140–148 145–157 152–172 (173) (64–67) (66–71) (69–78) 59 100 144–154 151–163 158–180 (178) (65–70) (69–74) (72–82) 69 00 149–160 157–170 164–188 (183) (68–73) (71–77) (75–85) 69 20 155–168 164–178 172–197 (188) (70–76) (75–81) (78–90) 69 40 162–172 171–187 181–207 (193) (74–78) (78–85) (82–94) Women Small Frame Medium Frame lb (kg) lb (kg) 102–111 109–121 (46–50) (50–55) 104–115 113–126 (47–52) (51–57) 108–121 118–132 (49–055) (54–60) 114–127 124–138 (52–058) (056–63) Height ft in.
(cm) (kg) lb (kg) (kg) 59 60 120–133 130–144 140–159 (168) (55–60) (59–65) (64–72) 59 80 126–139 136–150 146–167 (173) (57–63) (62–68) (66–76) 59 100 132–145 142–156 152–173 (178) (60–66) (65–71) (69–79) 69 00 138–151 148–162 158–179 (183) (63–69) (67–74) (72–81) * In shoes with 1in. Table A–17 Comparative Nomenclature of Bronchopulmonary Anatomy Number (Color) Thoracic Key to Petit Society of Jackson–Huber Reviews Boyden Brock Great Britain Right Upper lobe Apical Apical Apical 1 (Red) B1 Pectoral Anterior Anterior 2 (Light blue) B2 Subapical Posterior Posterior 3 (Green) B3 Right middle lobe B4 Lateral Lateral Lateral 4R (Purple) B5 Medial Medial Medial 5R (Orange) Right lower lobe Apical Apical Superior 6 (Lavender) B6 Cardiac Medial basal Medial basal 7 (Olive) B7 Anterior Anterior basal Anterior basal 8 (Yellow) B8 basal Middle Lateral basal Lateral basal 9 (Red) B9 basal (continued) .Miscellaneous Reference Data  229 Table A–16 1983 Metropolitan Life Insurance Height and Weight Tables* (continued) Women Height Small Frame lb Medium Frame Large Frame lb ft in. heels and clothes weighing approximately 5 lb.
230  Appendix Reference Data Table A–17 Comparative Nomenclature of Bronchopulmonary Anatomy (continued) Number (Color) Thoracic Key to Petit Society of Jackson–Huber Reviews Boyden Brock Great Britain Posterior Posterior basal Posterior basal 10 (Turquoise) B10 basal Left upper lobe Upper division 1–3 (Red) Upper division Apical and Apicoposterior Apical–posterior B1&3 subapical or apical and posterior Anterior 2 (Light blue) B2 Pectoral Anterior Lower (lingular division) B4 Superior Superior linSuperior lingular 4L (Purple) lingular gular (Orange) B5 Inferior Inferior linInferior lingular 5L lingular gular Left lower lobe Apical Apical Superior 6 (Lavender) B6 Anterior Anterior basal Anteromedial 8 (Yellow) B7&8 Middle Lateral basal Lateral basal 9 (Red) B9 basal Posterior Posterior basal Posterior basal 10 (Turquoise) B10 basal .
1 32.4 31.0 1 yr 43 7.8 32.4 32.4 31.Miscellaneous Reference Data  231 Table A–18 Incubator Temperatures According to Age Birth Weight 72500 g and Gestation 736 wk 8C 8F 33.5 92.1 89.3 90.1 89.3 33.8 33.4 90.5 88.3 33.4 92.5 92.1 89.7 90.2 32.5 92.6 30.5 85.8 32.1 89.7 8.8 11 6.0 Adult 90–150 14–18 22 12.3 33.5 92.1 — — Age (day) 1st 2nd 3rd 4th 6th 8th 10th 12th 14th Birth Weight 61500 g 8C 8F 34.8 32.9 89.6 16 yr 74 14 20 10.4 90.4 29.9 32.2 86.5 92.3 33.3 93.0 91.1 89.0 30.9 87.3 5 yr 56 10 13.5 92.8 32.4 92.5 10 yr 63 11 14.6 30.4 32.8 Table A–19 Airway and Alveolar Dimensions from Birth to Adult Trachea Bronchus Length Diameter Length Diameter Age (mm) (mm) (mm) (mm) Birth 40 6 9 5.6 87.5 7.3 33.7 92.3 33.7 33.7 Number of Alveoli 24 3 106 129 3 106 250 3 106 280 3 106 290 3 106 296 3 106 .1 Birth Weight 71500 g 8C 8F 33.
+ ? + + + + + + GramNegative Bacteria 0 2 . + + + + + + + Tubercle Bacillus Spores 0 0 0 ? + + + + + + 0 0 0 ? 0 . . = fair. . . ? + + + + + = good. + + + + Fungi 0 0 . ? .232  Appendix Reference Data Table A–20 Approximate Daily Requirements of Calories and Water Age Calories Water (yr) (kg) (mL/kg) Infancy 110 150 1–3 100 125 4–6 90 100 7–9 80 75 10–12 70 75 13–15 60 50 16–19 50 50 Adult 40 50 Table A–21 Capabilities of Disinfecting Agents Commonly Used in Respiratory Care* GramPositive Bacteria 0 . . ? = unknown. .1008C) Glutaraldehydes Hydrogen peroxidebased compounds Steam (. . + + Disinfectant Soaps Detergents Quaternary ammonium compounds Acetic acid Alcohols Hot water (. 0 = little or none.1008C) Ethylene oxide * Viruses 0 0 . . 2 = poor.
Miscellaneous Reference Data  233 Table A–22 Variables and Calculated Parameters for Characterizing Nebulizer Performance Variable Symbol Primary Measured Variable or Equation Output Flow OF Primary measured variable Initial Charge IC Primary measured variable Retained Charge RC Primary measured variable Inhaled Aerosol IA Primary measured variable Lung Deposition LD Primary measured variable Output Aerosol OA OA = IC – RC OA Output Rate OR OR = NT Inhaled Aerosol Rate Wasted Aerosol Exhaled Aerosol Nebulizer Efficiency Conserver Efficiency IAR WA EA NE CE IAR = IA NT WA = OA – IA = IC – RC – IA EA = IA – LD OA NE = IC CE = SE IA – BE = – BE = DE – BE NE OA (continued) .
234  Appendix Reference Data Table A–22 Variables and Calculated Parameters for Characterizing Nebulizer Performance (continued) Variable Symbol Primary Measured Variable or Equation BE Breathing Efficiency OF b sin 21 a (assuming sinusoidal p f VT OF 1 b b b 1 VT 1 OF 3 ° 2 ° f 3 ° a 2 VT cos asin 21 a ¢¢¢ flow and CE = 0. see p f VT 2f pf IA Appendix) BE 5 5 OA OF Retention Efficiency RE = SE = (CE + BE) 3 NE = DE 3 NE = DE = TE = LD IA LD 5 3 5 RE 3 SE IC IA IC SE IA IC IA 5 3 5 5 CE 1 BE NE IC OA OA IA IC RE LD IA System Efficiency SE Delivery Efficiency DE Treatment Efficiency TE .
Translation of Commonly Used Words  235 ■■ translation oF CoMMonly used Words Table A–23 French Words English Baby Bed Blood Breath Breathe Cannula Chest Cough (n) Deep Disease Doctor Down Family Fast Head Heart Hood In Intensive Care Unit Lay Left Listen to Lungs Mask Mechanical ventilation Medication French Bébé Lit Sang Souffle Respirer Canule Thoracique Toux Profond Maladie Docteur En bas Famille Rapide Tête Coeur Coiffe En Unite de Soins Intensifs Poser Gauche Écouter Poumon Masque Respiration assistee Médication Approximate Phonetic Pronunciation BayBay Lee Sahng Sufl Respeer9ay Ka9nuel Thora9seek Too Profond9 Maladee Dock9tœr Abn9bah Fahm9eeyuh Rah9peed Teht Ker Kwaff Ahn Uni9tay duh Swähnzantawnzeef Pozay Gosh Aycoo9tay Poo9mahn Mahsk Rehspeerahseeawn ah see9stay Maydee9cahseeawn (continued) .
236  Appendix Reference Data Table A–23 French Words (continued) English Mist Mouth Mucous Name Needle No No smoking Normal Nose Nurse (female) Out Oxygen Oxygen tent Pain Patient Position Pulse Relaxation Rest Respiratory therapist Ribs Right Sit Sleep Slow Smoking Stomach Stop Take French Brume Bouche Mucus Nom Aiguille Non Défense de fumer Normal Nez Infirmière Hors Oxygène Tente à oxygene Douleur Patient Position Pouls Relâchement Repos Spécialiste de thérapie respiratoire Côtes Droit S9asseoir Sommeil Lent Fumer Estomac Arrêter Prendre Approximate Phonetic Pronunciation Bruem Boosh Mew9kus Noh Ay9geeyah Noh Duh9fonce duh foo9may Normal Nay An9firmee9air Or Oxy9jehn Tahnt9à oxy9jehn Doo9lure Pa9seeahn Pozee9seeon Pool Reh9lashmon Reh9po Spay9syaleest duh térapee reh9speerahtwahr9 Coat Drah Sahs9swahr So9mayuh Lawn Foo9may Ehstome9ah Ahreh9tay Prawn9druh .
Translation of Commonly Used Words  237 Table A–23 French Words (continued) English Tent Tube Turn Understand Up Yes French Tente Tube Tourner Comprendre En haut Oui Approximate Phonetic Pronunciation Tawn9tuh Tueb Toor9nay Comprawn9druh Onoh9 Wee Table A–24 Spanish Words English Spanish Baby Bebe Bed Cama Blood Sangre Breath Aliento Cannula Canula Chest Pecho Cold Resfrio Cough (n) Tos Deep Hondo Disease Enfermedad Doctor Doctor Down Bajo Family Familia Fast Rapido Head Cabeza Heart Corazón Hood Caja In Adentro Intensive Care Unit Unidad de Tratamiento Intensivo Lay Acostarse Phonetic Pronunciation Baybay Cahma Sangray Alee9entoe Khanula 9Paycho Res9freeo Tos 9Awndoe 9Ennfurmay9dodd Dock9tore 9Baho Fam9eeleeah 9RRahpeadoe Ca9bessa Cora9sone 9Caha All9thentro Uni9thad day Trata9mientoe Inten9seevoe Allcoe9starsay (continued) .
238  Appendix Reference Data Table A–24 Spanish Words (continued) English Spanish Left Izquierda Listen to Escuchar Lungs Pulmon Mask Mascara Mechanical ventilation Respiración mecánica Medication Mist Mouth Mucous Name Needle No No smoking Normal Nose Nurse (female) Out Oxygen Oxygen tent Pain Patient Position Pulse Relaxation Rest Respiratory therapist Ribs Right Medicina Vapor Boca Moco Nombre Aguja No Prohibido fumar Normal Nariz Enfermera Fuera Oxigeno Tienda para oxigenación Dolor Paciente Posición Pulso Descanso Reposo Terapista de respiración Costillas Derecho Phonetic Pronunciation Iskey9airda Escoo9char Pool9mun 9Mascarah Respearahsee9own mhe9khaneeca Medee9seena Vah9poor 9Boka 9Moekoe 9Nomebray Ah9gooha No Pro9eebay fu9mar Nor9mal Nar9eese Ennfur9mayrah Ah9fwayra Awk9seehayno Tea9enda para awk9seehayno Doe9lore Pasee9entay Po9seeseeown 9Poolso Des9khanso Re9poso Tayrah9peesta day respeerasee9own Kos9teeyas Day9raycho .
Translation of Commonly Used Words  239 Table A–24 Spanish Words (continued) English Spanish Roll over Darse la vuelta Sit Sentarse Sleep Dormir Slow Despacio Smoking Fumar Stomach Estómago Stop Alto Take Tomar Tent Tienda Tube Tubo Turn Vuelta Understand Entender Up Arriba Yes Si Table A–25 Italian Words English Baby Bed Blood Breath Cannula Chest Cough Deep Disease Doctor Down Family Fast Bambino Letto Sangue Fiato Cannula Torace Tosse Profondo Affezione Dottore Giu Famiglia Fermo Italian Approximate Phonetic Pronunciation Bahmbee9noe Leh9toe Sahn9gway Feeah9toe Cahn9noola Tohrah9chay Toss9say Prohfon9doh AfettsseeOh9nay Dohtor9ray Jew Fahmee9leeyah Fair9mo (continued) Phonetic Pronunciation 9Darsay la boo9ellta Sen9tarsay Door9mear Des9paseeo Fu9mar Ex9toemago 9Ahltoe Toe9mar Tea9enda 9Toobow Boo9ellta Enten9dair Are9reeba See .
240  Appendix Reference Data Table A–25 Italian Words (continued) English Head Heart Hood In Intensive Care Unit Lay Left Listen to Lungs Mask Mechanical ventilation Medicine Mist Mouth Mucous Name Needle No No smoking Normal Nose Nurse (female) Out Oxygen Italian Testa Cuore Cappuccio Entro Unita di trattamento intensivo Posare Sinistro Ascoltare Polmone Maschera Respirazione assistita Medicina Nebbia Bocca Muco Nome Ago No Vietato fumare Normale Naso Infermiera Fuon Ossigeno Approximate Phonetic Pronunciation Test9ah Kwoh9ray Cappoo9cheeo Ehn9troe Oonittah di trahtahmehn9toe Eenten9seevoh Poesah9ray Sihnee9stroe Ahskohltah9ray Polemoan9ay Mahskeh9rah Rehspeerahtsee9owenay ah9seesteetah Mehdihchee9nah Neh9beeyah Bock9kah Moo9koh No9may Ah9goe No Veeehtah9toe foomah9ray Normah9lay Nah9soe Eenfairmeeay9rah Foooh9ree Ohsee9jehnoe .
Translation of Commonly Used Words  241 Table A–25 Italian Words (continued) English Oxygen tent Pain Patient Pill Position Pulse Relaxation Rest Ribs Right Roll over Sit Sleep Slow Smoking Stomach Stop Take Tent Tube Turn Understand Up Yes Italian Tenda per ossigeno Dolore Paziente Pillola Posizione Polso Rilassamento Riposo Coste Destra Rivoltate Sedere Sonno Lento Fumare Stomaco Arrestare Prendere Tenda Tubo Voltare Intendere Su Si Approximate Phonetic Pronunciation 9Tehndah pair ohsee9jaynoh Doeloe9ray Pahtseeen9tay Peel9lohlah Pohzeetseeoh9nay Pole9soe Reelah9sahmen9toh Reepoe9so Coe9stay Deh9strah Reevoltah9tay Sayday9ray Sonn9noh Lehn9toe Foomah9ray Stoe9mahcoe Ahrresstah9ray Prehndeh9ray Tehn9dah Tube9oh Volltab9ray Eenten9dayray Soo See .
242  Appendix Reference Data Table A–26 Polish Words English Baby Bed Blood Breath Breathe Chest Cough Deep Doctor Down Family Fast Head Heart Hood In Lay down Lay on Left Listen to Lungs Mask Medicine Mist Mouth Needle No No smoking Normal Polish Babe Lozko Krew Dech Oddychac Skrzunic Kaszel Gleboki Dohor Dolle Rodzine Szybki Glowa Serce Kaptur Wewnatrz Skladac Nakladac Lewy Kogos Pluco Maska Medycyna Mgla Usta Igla Nie Nie wolno palic Normalny Phonetic Pronunciation Baabe Wooshko Krrev Deh Awddehhach Kshooneats Kashell Gwembokey Doktore Doughleh Rogeena Shipkee Gwova Seltze Koptour Vevnoonch Squaqdatch Nawquadach Levy Kogush Pwutzo Mawska Medetsina Mehgwa Uhstah EEgwan Nyeh Nyeh volno paleech Nanmawlne (continued) .
Translation of Commonly Used Words  243 Table A–26 Polish Words (continued) English Polish Nose Nos Nurse Nianka Out Na zew natrz Oxygen Tlen Pain Bol Patient Cierpliwy Position Posada Pulse Puls Relaxation Oslabienie Respiratory therapist Oddechowy terapia Rib Zebra Right Prawy Roll over Odwrocic Sit Siedziec Sleep Spac Slow Powolny Smoker Palacz Stomach Zoladek Stop Zatkac Take Brac Tent Namlot Tube Rura Turn Vi obracac Understand Rozumiec Gorze Up Tak Yes Phonetic Pronunciation Noss Kneeyanka Na Zev Nunch Telen Bole Cherpleavy Pawsada Pulls Oswabeeyenye Awddehhovy terrawpeaa Zehbra Prahvy Owdlvucheech Shehjetch Spahch Povolne Palech Zawwondeck Katch Bratch Nemwatt Rurah Vee Obrahchatch Rohzoommeech Goozech Tuk .
244  Appendix Reference Data Table A–26 German Words English Baby Bed Blood Breath Breathe Cannula Chest Cough Deep Disease Doctor Down Family Fast Head Heart In Intensive Care Unit Lay Left Listen to Lungs Mask Mechanical ventilation Medication Mouth Mucous Name Needle German Baby Bett Blut Atem Atmen Kanüle Brust Husten Tief übel Doktor Nieder Familie Fest Kopf Herz In Intensivstation Legen Links Hören Lunge Maske Assistielte atmung Arznei Mund Schleim Name Nadel Phonetic Pronunciation Baabe Bet Bloot Ah9tem Aht9men Kahn9oohluh Broost Hoo9stun Teef Ooh9buhl Dock9tohr nee9der Fah9meelyah Fest Cawpf Hairts In Inten9siv9stahts9eeohn Lay9gehn Lihnks 9Hœren Luhn9guh 9Mahskuh Assissteer9the aht9moong Arts9nye Moont Shlime Nahm9uh Nah9dul .
Translation of Commonly Used Words  245 Table A–26 German Words (continued) English German No Nein No smoking Rauchen verboten Normal Normal Nose Nase Nurse Kraukenschwester Out Aus Oxygen Sauerstoff Oxygen tent Sauerstoffzelt Pain Schmerz Patient Patient Position Stellung Pulse Puls Relaxation Entspannung Rest Pause Ribs Rippen Right Recht Sit Sitzen Sleep Schlaf Slow Nachgehen Smoking Rauchen Stomach Magen Stop Halten Take Nehmen Tent Zelt Rohr Tube Wenden Turn Verstehen Understand Auf Up Yes Ja Phonetic Pronunciation Nine rou9khen fairboh9ten Normal9 Nah9suh Krahnkenschwehst9er Ows Zou9er shtoff Zou9ershtoff9tsehlt Shmairts Patsi9ent Shtehl9oong Pools Ehntspah9noong Pou9suh Rih9pehn Rehkt Zit9sen Shlahf Nahkh9gayehn Rou9khen Mah9gehn Hahl9ten Nay9men Tselt Roar Ven9den Fairstay9en Ouf Yah .
Clap between the clavicle and the top of the scapula on each side. anterior segment. apical segment. Clap between the clavicle and nipple on each side. Patient lies on his back with knees flexed. . Patient sits and leans back on a pillow at a 30degree angle against the therapist. Figure A–2 Upper lobes.246  Appendix Reference Data ■■ Postural drainage Positions Figure A–1 Upper lobes.
(about 15 degrees).Postural Drainage Positions  247 Figure A–3 Upper lobes. medial segment. . In females with breast development or tenderness. The patient lies head down on the left side and rotates one quarter turn backward. Figure A–4 Right middle lobe. The knees should be flexed. use cupped hand with heel of hand under armpit and fingers extending forward beneath the breast. lateral segment. Patient leans forward over a folded pillow at a 30degree angle. Clap over the right nipple. Clap over the upper back on both sides. posterior segment. Bed is elevated 14 in.
superior segment. Figure A–6 Lower lobes. left upper lobe. Patient lies on abdomen with two pillows under the hips.248  Appendix Reference Data Figure A–5 Lingular segment. superior segment. Clap over the left nipple. Patient in a headdown position on the right side and rotated one quarter turn backward. . Clap over the middle part of the back at the tip of the scapula on either side of the spine. inferior segment.
Clap over the uppermost portion of the lower ribs. and rotates one quarter turn upward from a prone position. (approximately 30 degrees). The patient lies on his side with a pillow between the knees. lateral basal segments. The foot of the bed is elevated 18 in.Postural Drainage Positions  249 Figure A–7 Lower lobes. Figure A–8 Lower lobes. (about 30 degrees). head down. The foot of the bed is elevated 18 in. The patient lies on his abdomen. Clap over the lower ribs just beneath the axilla. anterior basal segments. The upper leg is flexed over a pillow for support. .
with a pillow under the hips. The patient lies on his abdomen. (about 30 degrees). (1) The anterior segment of the upper lobes is drained in a supine position at a 30degree upright angle. (3) The posterior segment of the right upper lobe is drained in a prone position with the right side elevated 45 degrees. (4) Drain the anterior segment of the upper lobe in a supine position. Clap over the lower ribs close to the spine on each side.250  Appendix Reference Data Figure A–9 Lower lobes. head down. The foot of the bed is elevated 18 in. posterior basal segments. (2) Drain the apical segment of the right lung while the infant lies on his left side at a 30degree upright angle. . 1 2 3 4 5 Figure A–10 Positions for chest physiotherapy.
. (5) The posterior basal segments of the lower lobes are drained at a 30degree. (3) Drain the anterior basal segments of the lower lobes at a 30degree. headdown position. headdown position while the infant is lying on his side. rotate to the right. headdown angle. (2) The superior segments of the lower lobes drain in a prone position. with a 45degree rotation to the left. To drain the lingula. (4) The basal segments of the lower lobe are drained at a 30degree.Postural Drainage Positions  251 1 2 3 4 5 Figure A–11 (1) The right middle lobe is drained at a 15degree. headdown prone position.
.
128t AIS score. common. 221t Aerosol particles. capabilities of. units of. 130t oral. oxygen consumption for. 232t Acidbase disorders classification of. 38 prediction equations for. See Abbreviated Injury Scale score Alcohols. 21 Adaptive control. 231t Airway obstruction. See APACHE II score Acute respiratory distress syndrome. 5 Abbreviations. 128t dimensions of cuffless pediatric tracheostomy tubes. 188 Adults. helium therapy and. 77 Aerosol deposition. targeting schemes. dimensions of. A Abbreviated Injury Scale score. tables are noted with a t. 43. capabilities of. 171 in scientific notation. 38t Airways. 232t . 129t dimensions of lowpressure cuffed adult tracheostomy tubes. deposition of (mouth breathing). 83 Stewart approach to. based on Stewart independent variables. physical factors in. 130–131t approximate equivalents of various tracheostomy tubes. 172 of fractions with same denominator. 38t Airway dimensions. 132t approximate equivalents of various endotracheal tube sizing methods. 203t defined. 128–132. 161 Addition of fractions with different denominators. 175 Addition rule. acidbase map for. 43t Acute Physiology and Chronic Health Evaluation.INDEX Note: Italicized page locators indicate a figure. commonly used. 38 prediction equations for. from birth to adult. 150 conversion factors for. 75 Activities. 109 Acceleration. probability. 129–130t guide to choice of endotracheal tubes. defined. 133 appropriate suction settings vacuum settings for. 133 Airway resistance (Raw). 131t laryngoscope blades. 206 Acetic acid. equation for. 210 Absolute humidity. 161 Adaptive Support Ventilation. 221t Airway conductance (Gaw) defined. 118 Airway opening. in respiratory care. in respiratory care. 81–82 Traditional approach.
on inspired oxygen tension. 78 Antilogarithm (antilog). 16 Apothecary system. 62t normal. on inspired. 59 prediction for normal. 33t Amount of substance base unit of SI. 53t effect of. 205 Ampere. 58 nomogram for. 62t assessment of hypoxemia in newborn and elderly patients. 202t currently accepted nonSI units. 101t Alveolararterial oxygen tension gradient. 110–112 data. in trigonometry. 78–79 abbreviation. generating. and normal value for. 3 APACHE II score. 184 Antoine equation. and arterial oxygen tension. 137 typical values for. alveolar. from birth to adult. 186 Anion gap. 6 diagnostic categories weight leading to ICU admission. 78 equations for. 32. 203 Angles. 202t in respiratory physiology. 7–8t Apgar score. on Pao2 during oxygen administration. equation for. 231t Alveolar oxygen tension altitude’s effect on. 220t ARDS. 111t uses for. units. 17 observations related to. 137 defined. 57 Alveolar pressure. while breathing room air. prediction equations for. 110 water vapor pressure. 17t interpretation of. scores used in. 199t. 154 above set PEEP. 163 # Alveolar ventilation 1VA2 calculating. 55 mean. 112 APACHE article (original). units. 50 Alveolar dimensions. 60–62 abbreviation. 201t representative derived units. 55 effect of. 52t effect of. 61t Alveolar carbon dioxide equation.254  Index Altitude Denver and Mt. measurement units in. 60 . 111–112t water vapor pressure and content as function of temperature from. 78–79 function of. and percent saturation. 61 prediction equations for determining oxygenation impairment for sitting subjects. 58 graph relating expected Pao2 during oxygen administration based on measured Pao2 of room air. 9–10t severity of illness scored with. 56 effect of. while breathing room air. and normal value for. comparison of bloodgas values at sea level and. 60 assessment of hypoxemia in adults and children. on trapped gas. 199t conversion factors for. 56–57 nomogram of equation for. normal value for. units. See Acute respiratory distress syndrome Area conversion factors for. 199t Arterialalveolar oxygen tension ratio abbreviation. content. 187 Angular measure systems. Everest.
weight. normal value for. combined gas law and. 227t Body temperature and pressure. 81–82 strong ion difference. 81–82 BiPAP. units. 73 Stewart approach to acidbase disorders. 157 mandatory. 220t B Base. 80–81 deltadelta gap. 70–71 Body conditions converting gas volumes from room temperature to. 103–104 derivation of density of gas and. 106 Bicarbonate ion formulation equilibrium. percent by volume. altitude’s effect on. 123t ATPS (ambient temperature and pressure. 159. 174 Base excess abbreviation. 92 Breathing cycles. equation for. 217 ATPD (ambient temperature and pressure. 82 strong ion gap. 67 Assisted breath. dry).Index  255 Arterial oxygen tension. 157 Breath sequences categories of. 55 Arteriovenous oxygen content difference abbreviation. components of carbon dioxide curve for. 98–99 Body surface area average. 159 . 101t examples of. 78–79 base excess. 157 Association for the Advancement of Automotive Medicine. 227t prediction equations for. 80 defined. 78 Bloodgas analysis. 80 equations for. equations for. oxygen availability and. 66–67 equation for. and height. 73–83 anion gap. mechanical ventilation and. 123t Average. 168 Atmospheric content. 156–157 spontaneous. 83 Bloodgas measurements. 125t Atomic weight. 103 Avoirdupois system. 100 Brain hypoxia. normal value for. 99–101 effect of altitude on trapped gas and. 159–160 defined. 80–81 Bernoulli theorem. 65–66 whole. saturated. 157 loaded. 5 Associative axiom. 160 mode of mechanical ventilation and. to age. 190 Avogadro’s law. 144 Breaths assisted. 79–80 HendersonHasselbalch equation. 113–114 Blood oxygen content of. units. measurement units in. 103–104 equations for. 216 Bloodoxygen dissociation computation. 144 Breathing frequency defined. saturated with water vapor). 205 Boyle’s law. 161 Blender system equations. 226t pediatric chart. 160 unassisted. 159.
90 CGS measurement system. units. 107t for oxygen in blood. 42t Bronchopulmonary anatomy. 62t CL. 2 Chest physiotherapy positions. 232t Candela. 225t Caucasians. normal value for. approximate daily requirements for. See also Infants. 41t. 42–43 Cartesian plane. unit. Fahrenheit interconversions with. 208 Celsius temperature. 133 Children. 19 hypoxemia assessment in. 86–87 abbreviation. 101–102 Charlson Comorbidity Index. 39 prediction equations for. See Body temperature and pressure. 77 hypotension in. calculating dosages from. 24t CMV. 41–42. 218 Carbonate ion formation equilibrium. 181 . 178 Cathecholamine index. of logarithm. 66 defined. 118 Calories. 222t Centimetergramsecond measurement system. units. 84 equation for. dimensions from birth to adult. 21 Catheters. 44t Cardiac index. normal value for. lung function values for. 81–82 Carbon dioxide output defined.256  Index Bronchial inhalation challenges. 32 Celsius scale. defined. patterns of response to exercise with. 24. 49 equation for. conversion table for. Vo2 peak measurement for. 207 Central venous pressure. See Continuous mandatory ventilation Coefficients in quadratic equation. See Body surface area BTPS. 69 C Calibration factor. 101 examples. 204 Capacitance coefficient. 199t. equation for. normal value for. 84 Cardiac output abbreviation. 88. Neonates acidbase map for. 101–102 equations for. of flowmeter. 84 arteriovenous oxygen content difference and. 49 rebreathing experiments or confinement in enclosed area. 39t Cardiac disease. 217 Bunsen solubility coefficients. See Lung compliance Clinical Pulmonary Infection Score. 229–230t Bronchus. normal value for. 87t Cerebral perfusion pressure abbreviation. equation for. 49–50 Carbon monoxide diffusing capacity defined. 84–85 equation. comparative nomenclature of. 250–251 Chest wall. 90 equation for. saturated BTPS (body temperature and ambient pressure. 183 Charles’s law. saturated with water vapor at body temperature). 85 use for. See Centimetergramsecond measurement system Characteristic. units. 123t Buffer solutions. 208 Capsules. 86 hemodynamic parameters for. 231t BSA. 84 Cardiopulmonary stress tests.
defined. 81–82 Constant of proportionality. 187 CSV. units. 80 Correlation coefficient (Pearson r). 182 rules of. 138 for chest wall. 187 Cosine. 138 dynamic. 141 Cycle variable. normal value for. equation for. 182–183t Communityacquired pneumonia. 90 Corrected standard base excess. defined. dimensions of. 140 static respiratory system. computing. 187 Cotangent. 98–99 Coronary perfusion pressure. prefixes and symbols for. dimensions of. 117–118 Compressed volume. 163 calculated. 157 Conversion equivalents. lowpressure. K factors (L/psi) to calculate duration of. 79 equation for. 65 defined. 53t Dependent variable. 79–80 abbreviation. 98 Common logarithms. 80 function of. 23 Commutative axiom. 179 Continuous mandatory ventilation. 174 Combined gas law. 26 Degrees radians and.Index  257 in scientific notation. 79 Denominator. 152 Compressor. in respiratory care. 104 Dead space volume (Vd) clinical calculation of. 152 static. equation for. 139 in respiratory physiology. liquid and weight. equation for. 186 in trigonometry. 129–130t Cuffless pediatric tracheostomy tubes. equation for. 208 Conservation of mass A. 202–203t Converting gas volumes from. 28–29 pulmonary embolism and. See Central venous pressure Cycle. for units commonly used in medicine. 202t defined. 159 Continuous spontaneous ventilation. 140 of lung. 129t C/Vl. combined gas law and. 186 Deltadelta gap. 141 typical values for. comparison of bloodgas values at sea level and altitude in. 168 Compliance. 232t . See Continuous spontaneous ventilation Cuffed adult tracheostomy tubes. 158 Cylinder flow. 160 Control variable. 191–192 Cosecant. 138–139 conversion factors for. 220–221t Conversion factors. equation. defined. 178 Detergents. 138 patient circuit. 169 Denver. capabilities of. 29 original score. 208 specific. 141 Conductance. calculating duration of flow from cylinder of. See Specific compliance CVP. 140 Compressed gas. 33t Decimal multiples and submultiples. mechanical ventilation and. 199t Deep venous thrombosis Wells score for modified score. 119t D Dalton’s law of partial pressures. calculating. mechanical ventilation and. defined.
62t Electrical charge equation. capabilities of. defined. 26 Diffusing capacity of lung expressed as volume. 42 Expiration. 163 Expired. symbol for. 163 calculating. 180–181 Equivalent weight defined. or capsules. average rates of. approximate equivalents of.. targeting schemes. 174 Extracorporeal membrane oxygenation. 26 . 113–114 Equation of motion defined. 175 DLco. 199t Endexpiratory alveolar pressure or autoPEEP. 174t in scientific notation. 163 Endotracheal tubes guide to choice of. in U. 163 Expiratory time. 212 Disinfecting agents. determining appropriate length of insertion for. 170–171 in scientific notation. oxygenation index and. 218–219 from stock solutions. 130–131t Energy expenditure. 217 of serum calcium. 232t Exercise. 63 F Factorial notation(!). 131t infants. 179–180 quadratic. 164 Expiratory resistance. patterns of response to. 143–144. 189 Fahrenheit temperature. for men and women. See Extracorporeal membrane oxygenation Elastance (E). See Carbon monoxide diffusing capacity Drug dosage calculations from percentstrength solutions. 232t Distributive axiom. 132 sizing methods. tablets. 140 E ECMO.. in respiratory care. 168 Division of fractions. 140–141 Dynamic compliance defined. defined. 45 maximum oxygen consumption. Celsius interconversions with. 143 Expiratory time constant. defined.S. 32 Ethylene oxide. 204 Ethnicity. mechanical ventilation. hypoxemia assessment in. 218 Dual control. 122 Difficult weaning. 143–144 defined. 42t Entrainment system equations. 212 Exponents. mathematical models of pressurecontrolled mechanical ventilation and. components of. 141–142 DVT. 142–143 Equations linear. lung function values and. base unit of SI. 42–45 maximum heart rate. in respiratory care. mechanical ventilation. 142 equations for. 81–82 Electric current. 222t Failed spontaneous breathing. See Deep venous thrombosis Dynamic characteristic. 142. 45 resting energy expenditure. 174 rules for. representative. 208 Elderly patients.258  Index Diameter index safety system. capabilities of. 161 Duty cycle. 44t Exercise physiology. dynamic compliance vs. 42–43 maximum oxygen pulse.
derivation for lowflow oxygen system. 212 Forced expiratory flow 25%–75% (FEF25%–75%). related to some portion of FVC curve. 235–237t Frequency breathing. 37t Forced expiratory volumeforced vital capacity ratio defined. percent by volume. defined. 123t K factors (L/psi) to calculate duration of cylinder flow. approximate. 37 prediction equations for. 36t Forced vital capacity defined. See Forced vital capacity G Gas cylinders. 119–121 approximate number of hours of flow. defined. 170–171 for generating random numbers. defined. 196 Falsepositive rate. 108 Flow resistance. 117–118 helium therapy. 176–180 defined. 178 graphic representation of. defined. 36t Fractional concentration of carbon dioxide in expired gas. 202t representative derived units. See Functional residual capacity French words. 199t in respiratory physiology. 169–172 addition and subtraction of. 114–117 Functional residual capacity. with different denominators. 84 Fick’s law of diffusion. 163 representative derived units. equation for. oxygen consumption as function of age and heart rate for. See Forced expiratory volumeforced vital capacity ratio Fick principle. 216 Fractional concentration of oxygen. defined. 144 breaths/min. 36 prediction for mean normal FEV1/ FVC ratio (%). 170 multiplication property of. 199t ventilator. 169–170 FRC. 37t Forced expiratory volume in 1 second defined. with same denominator. 124t effects of breathing oxygen during hyperbaric therapy. 34t typical values for.Index  259 Falsenegative rate. See Forced expiratory volume in 1 second FEV/FVC. 172 addition and subtraction of. 34t Functions. 178 linear. translation of. 150–151 Force conversion factors for. 36 prediction equations for. 125t gas volume correction equations. 118 working tables and figures. 206 Forced expiratory flow. 178–179 FVC. 125t conversion figures to correct volume (ATPS) to volume (BTPS). 117–125 duration of. 171 division of. 37 defined. 144 ventilator (as related to gas exchange). 198 multiplication of. 216 Fractions. 144 Fio2. 119t atmospheric content. 34 prediction equations for. 196 Females. 94t FEV1. 36 prediction equations for. 119t . 143 defined. commonly used.
65–66 oxygen uptake. 66–67 carbon dioxide output. 122 schematic illustration of components of representative diameter index safety system. 106 Boyle’s law. 50 alveolar oxygen tensions. 65 equations for human bloodoxygen dissociation computation. 104 Fick’s law of diffusion. 49–50 clinical calculation of dead space. conversion factors for. 63–64 respiratory exchange ratio. 106–107 Law of Laplace. translation of. 244–245t Glasgow Coma Scale. 68 venoustoarterial shunt (clinical form). defined. 125t Gas exchange. 123t Gauge pressure. 71 oxygenation index. 119t medical gas cylinder dimensions. 48 partial pressure of inspired oxygen. 105–106 Gas transport. CGA standard. 145 General gas law. 99–112 absolute humidity. 109 Antoine equation. 110–112 Avogadro’s law. 62 oxygen content of blood. 98–99 General linear equation. 50–51 venoustoarterial shunt (classic form). 102–103 GoffGratch equation. 120t new standard threaded valve outlet connections for medical gases. 122 Gas diffusion. 121t physical characteristics of gases. 67 ventilator frequency related to. 179 German words. 110t Graham’s law. 56–57 arterialalveolar oxygen tension ratio. defined. 68–69 ventilationperfusion ratio. 99–101 Charles’s law.260  Index medical gas cylinder color codes. 51–52 physiologic dead space (Bohr equation). in respiratory care. 45 . 120t medical gas cylinder specifications. behavior of. 23 Heart rate reserve. 206 Gram molecular weight. 206 Gramforce. 110. 203t Gases ideal. 104–105 relative humidity. 101–102 Dalton’s law of partial pressures. 63 oxygenation ratio. 109 Reynold’s number. capabilities of. 51 respiratory quotient. defined. 58–60 arteriovenous oxygen content difference. 98 physical characteristics of. 232t Gram metric system. 125t PPLT index. 144 Gas laws. 103–104 Bernoulli theorem. 108–109 Poiseuille’s law. special. 107 Henry’s law. 108 GayLussac’s law. 60–62 alveolar carbon dioxide equation. commonly used. 70–71 hemoglobin affinity for oxygen. defined. 203t Gas volume correction equations. 217 H Healthcareassociated pneumonia. 3 Glutaraldehydes. 48–73 alveolararterial oxygen tension gradient. conversion factors for.
226t Hypotension. 90 mean arterial pressure. Metropolitan Life Insurance (1983) height and weight tables. 12–13t Hot water. 73 HendersonHasselbalch equation. 228–229t Helium. See Maximum heart rate HRR. See Heart rate reserve Humidity absolute. 118 Helium therapy. 92 oxygen consumption. 87–88 Hemodynamic variables. defined. 2001 expanded criteria for sepsis and. 75t function of. in respiratory care. 90–91 right cardiac work index. 106– 107. 72 oxyhemoglobin dissociation curves. in respiratory care. in newborn and elderly patients. 20 Hemoglobin affinity for oxygen. flow chart. 23 Hospital mortality.Index  261 Height. capabilities of. 107 Hertz (Hz). 88–89 vascular resistance. 86–87 cerebral perfusion pressure. 85–86 stroke volume. 85 stroke work. 84–85 cardiac output. characteristics of. 74 Henry’s law (Law of solubility). 92–94 oxygen extraction ratio. diameter index safety system. bicarbonate concentration and Pco2. 77 components of carbon dioxide curve for whole blood. 73–74 acidbase interpretation scheme. 208 Bunsen solubility coefficients. 86 oxygen availability (delivery). 71 nomogram relating Po2 and oxygen saturation. 62t assessment of. 73 modified SiggaardAnderson nomogram relating blood pH. 232t Hyperbaric therapy. 74t rearrangement of. 91 systemic vascular resistance. 90–92 left ventricular stroke work index. 84–95 cardiac index. capabilities of. in adults and children. 62t . 107t equations for. 77 acidbase map for neonates. conversion table for. 125t Hypodermic needle tubing. 109 Hydrogen peroxidebased compounds. 90 coronary perfusion pressure. 19 Hypoxemia assessment of. 78 expected compensation for simple acidbase disorders. 109 relative. 76 acidbase map for children and adults. 84 central venous pressure. Simplified Acute Physiology Score. 118 Hemodynamics. blender and entrainment system equations and. 89 stroke index. 122 Home care ventilator. 71–73 factors shifting curve. 94–95 pulmonary vascular resistance index. effects of breathing oxygen during. 232t HRmax. 199t Hex nut. 76 ranges and nomenclature for pH and Paco2. 113–114 Hospitalacquired pneumonia. 92 right ventricular stroke work index.
17t assessing. defined. 203 Kilogram. equation for. 63 chest physiotherapy positions for. 20 Injury Severity Score. 163 Inspiratory time. 147 Inspiratory triggering response time. 116–117 Inspired oxygen tension. symbol for. 178 Infant endotracheal tubes. 199 Interstitial lung disease. 250–251 Infection. exercise response patterns with. 5 Inotropic score. tidal volume and. 98 IMV. 199t . 26. 207 K Kelvin (K). 132 Infants Apgar score for. defined. 163 Inspiratory triggering flow. 33 Inspiratory work per breath. See Inspiratory vital capacity J Joule (J). 145 mathematical models of pressurecontrolled mechanical ventilation and. 9–10t Ideal gas equation. 239–241t IVC. 231t Independent variable. 145 Inspiratory hold. before treatment with extracorporeal membrane oxygenation. 163 defined. 164 Inspiratory:expiratory time ratio defined. 217 ISS. 16–17. determining appropriate length of insertion for. translation of. 60–61 Intubation Difficulty Scale. 159–160 International System of Units. defined. equation for. defined. altitude’s effect on. 208 base unit of SI. 199t. defined. 147 Inspiratory triggering pressure. alveolararterial oxygen tension gradient and. 147 Inspiratory triggering volume. commonly used. 52t. 145 equation for. 199t defined. See Intermittent mandatory ventilation Incubator temperatures. postdelivery. 21 Inspiration defined. according to age. 145 defined. 109 Ideal gas law. 146 Inspiratory hold maneuver. 163 Inspiratory time fraction. 117 as function of oxygen flow rates and mixed air. targeting schemes. absolute humidity equation derived from. 213 Inspired oxygen concentration. 163 Inspired. 147 Inspiratory vital capacity. 20 expanded criteria for sepsis and. 152 Inspiratory relief valve. See Injury Severity Score Italian words. defined. 27t Isotonic solutions. defined. 145 Inspiratory flow calculating. diagnostic categories weight leading to. 55 Intelligent control. 146 Inspiratory time constant. 161 Intermittent mandatory ventilation.262  Index I ICU admission. 146 Inspiratory resistance. 44t Intrapulmonary shunting. 19.
93t Mandatory breaths. units. 213 Lung volume. 91 equation for. 207 Knaus chronic health status score. 184 antilogs of negative logarithms. 206 Kilopascal (kPa). 116t Mass base unit of SI. 130t Law of Laplace (for a sphere). units. 179 solving. Poiseuille’s law and. 184 change of base. 206 Kilogramforce. 192 Liquid conversion equivalents. 133 symbol for. and household. hemodynamic parameters. 91 Left ventricle. 199t conversion factors for. 153 M Males. 178–179 Linear regression (method of least squares). 172 Left atrium. 202t conversion table for.Index  263 defined. 157 Logarithms. 104–105 Laryngoscope blades. 87t Left cardiac work index abbreviation. representative derived units. normal value for. 114–117 example. 164 of pressurecontrolled mechanical ventilation. 163–164 . metric. 108–109 Law of mass action. 21. apothecary. 116t derivation of approximate Fio2 for. 203 metric system. 39 prediction equations for. 184 natural. 184 MAP. 163 model assumptions. slope of. 182–185 antilogarithms. 159. hemodynamic parameters. 199t Mathematical models general equations. 182 mantissa. 39t Lung injury score (Murray score). 87t Left ventricular stroke work index abbreviation. 201t Mass density. 3 L Laminar fluid flow through tube. normal value for. base unit of SI. 185–186 characteristic of. 179–180 Linear functions. 179 Linear equations general. defined. 115 Luminous intensity. 220t Loaded breath. in lowflow oxygen system. 90 equation for. 160 Mantissa. oxygen consumption as function of age and heart rate for. 163–165 glossary. 185 Lowflow oxygen system. 223t Line. 73 Least common denominator (LCD). 182–183 defined. 39 measuring. See Mean arterial pressure Mask with reservoir bag. step change in airway pressure and change in. 164–165 for inspiration. 199t Lung compliance. 199t currently accepted nonSI units. HendersonHasselbalch equation and. 183 common. 22t Lungs schematic representation. 91 Length base unit of SI.
147 Maximum voluntary ventilation. CGA standard. 45 prediction equations for. 199t defined. 86–87 abbreviation. and targeting scheme. 52 classifying modes of. 164 Mathematical signs and symbols. 42 prediction equations for. defined. 86 defined. 159 patient and machine triggering and cycling. 158 ventilatory pattern. average rates of energy expenditure by. 22 Median. 121t PPLT index. 41. 159–160 control variable. 156–157 breath sequence. 86 equations for. defined. 147 McCabe classification. 196t Maximum expiratory pressure defined. 43t Maximum oxygen pulse defined. 42t Metabolic acidosis. 156 pressurecontrolled. 162t ventilatorfree days. 203 Methacholine challenge test. 190 Medical gas cylinder color codes. 120t new standard threaded valve outlet connections for. 147– 148. 38t Maximum working pressure. 45 Maximum safety pressure. 156–162 assisted breath. 128–132 calculating partial pressure of inspired oxygen. 75t Metabolic alkalosis.S. 190 Mean airway pressure. 25–26 mode. 163 Mean arterial pressure. ventilatory pattern. 40t Maximum heart rate defined. 160 definition of terms for. mathematical models of. See Mean forced expiratory flow during middle half of FVC Maximum oxygen consumption defined. expected compensation for. 192 Metropolitan Life Insurance (1983) height and weight tables. 228–229t Milliequivalent. 45 prediction equation for. 161 mandatory and spontaneous breaths. 128–165 airways. 75t Meter base unit of SI. 41t Method of least squares. 45t Maximum inspiratory pressure defined. 39 prediction equations for. 120t Men. 86 Mechanical ventilation. units. 38 prediction equations for. 157 breath.264  Index for single expiration. 163–165 selection of modes named by manufacturers classified using taxonomy built from 10 aphorisms. defined. 121t. 2–3 Mean. 39 prediction equations for. 160–161 trigger and cycle variables. 39t Maximum midexpiratory flow rate. defined. 122 specifications. 132–156 definitions for weaning and liberation of.. normal value for. in U. 119t dimensions. 205 . 38 defined. 158–159 targeting schemes. expected compensation for. 157 control variable.
184 Obstructive lung disease. 193 Normal solution. 163 typical values for. 113–114 . See lung injury score MVV. 199t defined. 205 MOP. 122 NonSI units. 40t pulmonary function profile. 217 Osmole solution. 44t Obstructive pulmonary disease assessing severity of. 148 Minimum working pressure. 204 Mole/valence. 33t Mode of mechanical ventilation. 196 Neonates. defined. hemoglobin affinity for. 40t Optimum control. 205 Molar solution. 6 Osmolar solution. in trigonometry. in lowflow oxygen system. 199t n factorial. 217 Millipascalmeter. 170 in scientific notation. summary in. 18 Newton (N) defined. defined. Multiple Organ Dysfunction score and. 201t Normal distribution curve defined. characterizing. 206 SI representative derived unit. 217 Molar concentrations. Everest. targeting schemes. defined. 18t Silverman score for. 148. probability. defined. exercise response patterns with. defined. 116t Natural logarithms.Index  265 defined. defined. 194 Numerator. 156 MOD score. defined. 185 Nebulizer performance. 11t defined. 169–170 Multiplication rule. defined. 17. See Maximum voluntary ventilation N Negative predictive rate. 18. diameter index safety system. 188–189 Murray score. 11t Sequential Organ Failure Assessment score and. 189 Nipple. defined. 113–117 blender or entrainment system equations. 217 Oxygen. 148 # Minute volume 1VE2 defined. acidbase map for. 11. currently accepted. 77 Newborns hypoxemia assessment in. 193 standard deviations in. 168–169 Organ dysfunction in critically ill patients. 187 Negative logarithms. variables and calculated parameters for. 19 Multiplication of fractions. defined. 233–234t Negative angle. 217 Null hypothesis. 149 Mt. 71–73 Oxygen administration. 53t Multiple Organ Dysfunction score. 62t Respiratory Distress Scoring system for. 207 Minimum safety pressure. See Multiple Organ Dysfunction score Molal solution. 217 Mole base unit of SI. See Maximum oxygen pulse Motor. dimensions of. 175 Multiplication property of fractions. 11 severe sepsis and. 169 O Nasal cannula or catheter. 138t Order of precedence. 161 Oral airways.
92 defined. 43t Oxygen uptake defined. 48 P Parabola. 94 defined. 37t Peak inspiratory pressure compliance and. mechanical ventilation and. 92 defined. normal value for. equation for. 94t as function of age and heart rate for males. in lowflow oxygen system. 51–52 Partial pressures of gas in air at sea level. 139. units. normal value for. 104 normal. abbreviation. 114–117 Oxygenation index abbreviation. units. 93t prediction equations for females. 48 equations for. units. 163 Pearson r. defined. Dalton’s law and. 117 Oxygen mask. 116t Oxygen requirements. 92 equations for. 66 Oxygen extraction index abbreviation. 94 Oxygen flowmeter. normal value for. 116. units. of respired gases. 37 prediction equations for. 149 PCCMV. 93–94 males. See Pressurecontrolled continuous spontaneous ventilation PCIMV. 92–94 abbreviation. 118 Oxygen flow rates. 93 as function of age and heart rate for females. units. 191–192 Pediatric body surface area chart. normal value for. See Pressurecontrolled intermittent mandatory ventilation Peak expiratory flow defined. 158–159 Patient system. 65–66 abbreviations. 65 equations for. 63 Oxygenation ratio.266  Index derivation of approximate Fio2 for lowflow oxygen system. 181 Parameter. defined. 141 defined. normal value for. 95 equation for. units. See Pressurecontrolled continuous mandatory ventilation PCCSV. 227t . 207 Pascal (Pa). for common activities. normal value for. normal value for. 92 Oxygen consumption. 53 of inhaled gases. obtaining desired flow rate of given mixture with. 54 Pascalmeter. unit. 93 Oxygen content of blood. 62 Oxygen availability (delivery) abbreviation. 199t. 207 Patient initiated triggering and cycling. 149 Peak inspiratory pressure above set PEEP. 95 Oxygen extraction ratio abbreviation. 92 equations for. 194 Partial pressure of inspired oxygen.
in trigonometry. See Pediatric Index of Mortality II PIP. 139 Positive phase of flow waveform. 149 Percentage concentrations of solutions. breath. 248 lower lobes. defined. 15–16t Pediatric patients. units. 23 hospitalacquired pneumonia. 22–23 communityacquired pneumonia. 187 Positive endexpiratory pressure patient circuit compliance and. 208 surface tension. See Positive endexpiratory pressure Pemax. 249 lower lobes. 189 Pharmacological formulas and definitions. translation of. 207 Physiologic dead space (Bohr equation). anterior basal segments. 64 prediction equation for. 194 Positive angle. 204–208 amount of substance. left upper lobe. as defined by National Nosocomial Infection Surveillance System. defined. 5. 25t Pneumonia definitions. 19 Pediatric Risk of Mortality defined. 14t risk of death and predicted rate calculation. mode of mechanical ventilation and. 63–64 graph relating minute ventilation and Paco2 for different values of. 208 volume. 5t PEEP. 149 Pleural space. 246–251 lingular segment. 204–205 volume flow rate. 208 solubility.Index  267 Pediatric Index of Mortality II. 207 resistance. 207 pressure. 63 Pimax. clinical criteria for diagnosis of. defined. 64 reasons for ineffectiveness. inferior segment. 23 healthcareassociated pneumonia. 156 Positive predictive rate. 205–206 work and energy. defined. 217–219 Physical quantities in respiratory physiology. superior segment. 193 Permutations. 133 Pneumonia. 23 Poiseuille’s law. 250 . currently accepted nonSI units. 15 Pediatric Trauma Score. 196 Postural drainage positions. septic shock in. 23 ventilatorassociated pneumonia. 205 compliance. 219t Percentage preparations. 63 equation for. 201t Plateau pressure. 207 temperature. 141 abbreviation. See Maximum inspiratory pressure PIM II. 208 force. equations for. commonly used. 218–219 Percentile rank. types of. lateral basal segments. posterior basal segments. See Peak inspiratory pressure Plane angle. 242–243t Population. 104–105 Polish words. 249 lower lobes. See Maximum expiratory pressure Pendelluft. normal value for. 206 power.
superior segment. 189 multiplication rule. Minimum working pressure. apical segment. 163–165 Pressure control ventilation. mechanical ventilation. 199t Pressure conversion factors for. 247 upper lobes. 232t R Radians defined. 246 upper lobes. proximal airway pressure pattern and. fraction for. normal value for. lateral segment. 173 . 87t Pulmonary embolism. 181 Quaternary ammonium compounds. 28 Pulmonary function profile. normal value and equation for. 188–189 permutations. See Minimum safety pressure Pulmonary artery hemodynamic parameters.268  Index lower lobes. 247 Power. 189 Product. 160 Pressurecontrolled continuous spontaneous ventilation. Wells score for. 157 Proportions. 40t Pulmonary vascular resistance. in obstructive and restrictive diseases. 219 Ratios. 194 PW Min. 194 of breathing. 87t Pulmonary artery occlusion pressure. 207 Pressurecontrolled continuous mandatory ventilation. 224t representative derived units. mathematical models of. 203 relationships between degrees and. 198 “Ratio by simple parts” prescription. 186 SI units. 89 P value. medial segment. 181 Quadratic formula. 188 combinations. 173 PS MAX. 246 upper lobes. abbreviation. anterior segment. See Maximum working pressure PS Min. 174 Prolonged weaning. in respiratory care. 207 ventilator. 89 Pulmonary vascular resistance index abbreviation. See Plateau pressure Prefixes. hemodynamic parameters. 190 defined. 26. 180–181 in standard form. defined. 160 Pressurecontrolled mechanical ventilation. summary. 188 factorial notation (!). 153 Pressure drop. 163 in respiratory physiology. 160 Pressurecontrolled intermittent mandatory ventilation. 199 Random numbers. 197–198t generating. 186. 248 right middle lobe. 199t in respiratory physiology. 188–190 addition rule. 150 Pressure hold. 202t conversion table for. 26 Proportional Assist. 89 equation for. See Pediatric Risk of Mortality Probability. 150 PRISM. 149 PPLT. defined. capabilities of. for decimal multiples and submultiples. 148 Q Quadratic equations. posterior segment. defined.
40t pulmonary function profile. 105 pressure per unit flow. See Revised trauma score RV. hemodynamic parameters. 50 glucose and. See Respiratory Distress Scoring system REE. 91 equation for. 194 Residual volume defined. 50 for fat RQ. and abdominal wall components. with one compartment. 18t Respiratory exchange ratio defined. 51 Respiratory physiology. 51 equations for. for newborns. 204–208 Respiratory quotient defined. 42t Restrictive pulmonary diseases assessment of severity for. 35t Residual volume to total lung capacity ratio. defined.Index  269 RDS. See Resting energy expenditure Relative humidity. See Residual volume to total lung capacity ratio S Sample. 137t some pressure differences used for describing. 35 prediction equations for. See Standard base excess Scientific notation. defined. unit. 137t Resting energy expenditure defined. defined. and protein. 18. 35 Resistance airway. 199t Research hypothesis. symbol for. 134 schematic representation of. normal value for. hemodynamic parameters. 151 Respiratory acidosis. 105–106 Right atrium. 35t typical values for. 40t Reynold’s number. 75t Respiratory alkalosis. 216 in respiratory physiology. 75t Respiratory Distress Scoring system. 174–175 . 177 RTS. 150 Poiseuille’s law and. See Residual volume RV/TLC. 133 Respiratory system mechanics some measurable pressures used in. 203t defined. expected compensation for. lungs and chest wall subdivided into rib cage. diaphragm. fat. equation for. 91 Roots. 50 for mixture of glucose. 194 SBE. 87. 208 total respiratory. 92 Right ventricle. units. 33t Respiratory system diagram of. expected compensation for. 153–155 conversion factors for. 87t Right cardiac work index abbreviation. 92 equation for. and normal value for. 32 typical values for. 175 Rounding off. 51 Respiratory rate or frequency (f). 42 prediction equations for. summary in. 150–151 calculating. in scientific notation. 109 Representative derived units. physical quantities in. 87t Right ventricular stroke work index abbreviation. time constant and. 150 compliance times.
161 Setpoint control. defined. 6 severe sepsis and. capabilities of. 200–201t SI units. xiphoid retraction. 187 SI style specifications. 151 Significant figures. 232t SOFA score. 177 zeros as. 20–21 general variables. 211 . and Pco2. 76 Sigh. See Strong ion difference SiggaardAnderson nomogram. 20 hemodynamic variables. 33 Soaps. 174 multiplication and division. 208 Solute. 57 comparison of bloodgas values at altitude and. 176 Silverman score evaluation. 187 Second base unit of SI. use.270  Index addition and subtraction. 19 Servo control. 12–13t Sine. bicarbonate concentration. 198 Sensitivity. 20 organ dysfunction variables. 19 hypotension. commonly used. 26 Simplified Acute Physiology Score. defined. mechanical ventilation. in respiratory care. 53 Secant. 177 rounding off. 217 Spanish words. relating blood pH. 53t partial pressures of gas in air at. 19 septic shock. targeting schemes. 194 Sepsis 2001 expanded diagnostic criteria for. 219t Solvent. 18–19 Septic shock. chin movement. modified. 199–203 base units. 176–177 calculations with. 217 percentage concentrations of. 19 Sequential Organ Failure Assessment score. 199t SID. ventilator. 20–21 tissue perfusion variables. 237–239t Specific compliance defined. expanded version and. expiratory grunt. 217 Solutions defined. 19 infection. in respiratory physiology. 17 Simple weaning. translation of. See Sequential Organ Failure Assessment score Solubility. 18–19 clinical syndrome defined. 199t Slope of the line. 199t defined. targeting schemes. 18 upper chest. defined. representative derived units. 20 inflammatory variables. 175 Sea level alveolar air equation nomogram at. 175 advantages with. defined. 152 symbol for. 21 Sepsis definition. 19 severe sepsis. lower chest. 161 Severe sepsis. defined. 10t defined. defined. 19 systemic inflammatory response syndrome. 203 Seed number. 19 SI. 175 powers and roots. 179 Slow vital capacity. and interpretation of.
normal value and equation for. 83 Stock solutions. defined. 194–196 correlation coefficient (Pearson r). 190 normal distribution curve. 191–192 linear regression (method of least squares). 85 equation for. 204 SI units. 92 right ventricular stroke work index. calculating dosages from. 207 Survival. 190 mode. 190–191 median. dry). normal value for. 83 Subscripts. 190–196 common statistical terms. capabilities of. after bronchial challenge. 199t Standard base excess. 202t in respiratory physiology. 171 in scientific notation. 85 Stroke work. See Slow vital capacity Symbol conventions. 85 equation for. 82 Strong ion gap abbreviation. appropriate. 194 Statistical procedures. 172 of fractions with same denominator. 199 Stewart approach to acidbase disorders. in respiratory care. 135t . trauma score and. significant. 33–41 Spirometry changes. 80 Standard conditions. 41t Spontaneous breaths. classification of acidbase disorders based on. 85–86 Stroke volume abbreviation. 83 defined. 81–82 Stewart independent variables. 90–91 right cardiac work index. 159. units. 82 equations for. 85–86 abbreviation. 196 Sphere. defined. 91 Strong ion difference abbreviation. 132t Surface tension conversion factors for. 160 Square meter. 192 mean. 123t Stroke index. 175 Suction settings vacuum settings. 191 Steam. summary of. law of Laplace for. 108–109 Spirometry. pressure. 91 left ventricular stroke work index. 218 STPD (standard temperature and pressure. units. 90–92 left cardiac work index. and dry. units. 140 Statistic. torr. 6 Survival probability. 193 pecentile rank. 191 Static compliance defined.Index  271 Specificity. 140 Static respiratory system compliance. 4. 4t SVC. 232t Steradian defined. 205 Standard deviation. 193 standard deviation. normal value for. TraumaInjury Severity Score and probability of. normal value for. units. 211 Subtraction of fractions with different denominators.
151 Trachea. See Thoracic gas volume Thermodynamic temperature. 160–161 TCT. 35t Total respiratory resistance. 21 Torr. 242–243t Spanish. 33t Time base unit of SI. 32. 88 equation for. 136t Symbols of American College of Chest Physicians and American Thoracic Society Joint Committee. 201t for decimal multiples and submultiples. defined and points in. 88–89 abbreviation. 6 Trauma score. 2001 expanded criteria for sepsis and. 203t conversion table for. Evangelista. 38 Thorpe tube. 155 Total cycle time. mechanical ventilation. 214 Time constant. 196t representative derived units. dimensions of (in millimeters). 163 typical values for. 4. 143 TraumaInjury Severity Score. 39 equation of motion and. 146 defined. 237–239t Transpulmonary pressure calculating. 244–245t Italian. ranking. See Total cycle time TE. 239–241t Polish. 155 Torricelli. dimensions from birth to adult. calculating dosages from. normal value for. 88–89 T Tablets. 128t cuffless pediatric. 35t typical values for. 218 Tangent. 88 Systemic vascular resistance index. 200t mathematical. 211–215 base units of SI. 155 Total lung capacity defined. 199t currently accepted nonSI units. 152. 199t currently accepted nonSI units. 143 Transrespiratory pressure.272  Index Symbol modifier conventions. 231t in respiratory physiology. See Expiratory time Temperature conversion factors for. 4t . 163 calculating. 153–155 Time constant curves. 214 Tidal volume. 208 TGV. 201t symbol for. base unit of SI. normal value and equation for. defined. according to age. 199t Systemic inflammatory response syndrome. abbreviation. 222t incubator. 118 TI. 35 prediction equations for. 129t Translations of commonly used words French. dimensions of (in millimeters). 231t Tracheostomy tubes approximate equivalents of. summary of. See Inspiratory time Tidal. 187 Targeting schemes. 18–19 Systemic vascular resistance. 235–237t German. symbol for. 199t Thoracic gas volume. 129t lowpressure cuffed. 155 Tissue perfusion variables.
158 Trigonometric functions. 194 Vascular resistance. units. 68 Venoustoarterial shunt (clinical form) abbreviation. 202t conversion table for. 151 work. 160 . 173 Universe. 69 graph relating Pao2 and inspired oxygen concentration for different values of virtual shunt. defined. 68 equation for. 67 Ventilator sigh. defined. defined. 33 prediction equations for. 186–188 basic trigonometric identities. normal value for. 223t currently accepted nonSI units. See Minute volume Venous. degree and radius. conversion table for. 201t representative derived units. 157 Unit conversion. 70t Ventilationperfusion ratio abbreviation. 203t defined. Poiseuille’s law and. defined. 188 functions in. See Volumecontrolled continuous mandatory ventilation VCIMV. 22 Ventilator frequency defined. symbol for. normal value for. 215 Venoustoarterial shunt (classic form) abbreviation. 23 Ventilatorfree days. mechanical ventilation and. units. types of. 156 Ventilatorassociated pneumonia Clinical Pulmonary Infection Score and. 160 Vital capacity abbreviation for. 225t Type I error. 216 defined. See Vital capacity VCCMV. See Volumecontrolled intermittent mandatory ventilation Vd. 156 Trigger variable. See Inspiratory triggering response time Tube radius. 24 defined. 194 V VA. 194 U Unassisted breath. 187 systems of angular measure. 34t Volume conversion factors for. units. 87 equation for. See Alveolar ventilation Variable. 21 VC. defined. normal value for. 69 respiratory gas exchange and pressures. 105 Tubes. 187 Trigonometry. 186 TRISS. See Dead space volume # VE . 196 TTR. 34t typical values for. 68 equation for. 87–88 Vasopressor score. calculating. See TraumaInjury Scoring System. 87–88 conversion factors for. 149 Ventilatory patterns. 204 Volumecontrolled continuous mandatory ventilation. 196 Truepositive rate.Index  273 Trigger. 194 Type II error. 67 equation for. 199t in respiratory physiology. defined. 144 Ventilator power. TraumaInjury Severity Score Truenegative rate. defined.
and household. 206 conversion table for. 228–229t Weight conversion equivalents. defined. 232t Water dissociation equilibrium. 152 Volume to volume percentage preparations. equation for. See Maximum oxygen consumption VT. metric. tidal volume and.. 26.274  Index Volumecontrolled intermittent mandatory ventilation. 28–29 for pulmonary embolism modified score. apothecary. as significant figures. 28 original score. ventilator. 218 Wells score for deep venous thrombosis. 26 Weaning success. 42t Work. 223t Metropolitan Life Insurance (1983) height and weight tables. mechanical ventilation. 202t representative derived units. defined. 218 Weight to weight percentage preparations. in U. 207 Z Zeros. 26 Weight. equation for. in respiratory physiology. 199t in respiratory physiology. 156 Work and energy conversion factors for.S. 205–206 Volumelimited ventilation. See Inspiratory triggering volume W Water approximate daily requirements for. See Tidal volume VTR. defined. mechanical ventilation. 220–221t Weight to volume percentage preparations. average rates of energy expenditure by. 160 Volume flow rate. 81 Weak acid dissociation equilibrium. 176 . 28 Women. 207 Workenergy theorem. 81–82 Weaning failure. 218 Vo2 max.