Cairo: Pilbeam's Mechanical Ventilation, 7th Edition

Chapter 01: Basic Terms and Concepts of Mechanical Ventilation

WorkBook Answer Key

Key Terms Crossword Puzzle

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Chapter Review Questions

1. Ventilation refers to the movement of gas into and out of the lungs. Respiration is the
movement of gas molecules across a cell membrane.
2. External respiration, internal respiration.
3. The pressure at point A needs to be higher than the pressure at point B to create a
pressure gradient.
4. Intrapleural pressure, 5 cm H2O, 10 cm H2O.
5. a. A = Pressure at the airway opening (Pawo).
B = Airway pressure (Paw).
C = Pressure at the body’s surface (Pbs).
D = Alveolar pressure (Palv).
E = Intrapleural pressure (Ppl).
b. Mouth pressure (Pm), airway opening pressure (Pawo), proximal airway pressure, and mask
pressure.
6. Intrapleural pressure (Ppl) is estimated using the esophageal pressure (PES). PES is obtained
by placing a balloon in the esophagus and monitoring pressure changes in the balloon.
7. Transairway pressure (PTA), conductive airways, PTA = Pawo Palv.
8. Transthoracic pressure (PW or PTT), PW = Palv Pbs.
9. Transpulmonary pressure (PL or PTP), PL = Palv Ppl.
10. Transrespiratory pressure (PTR), PTR = Pawo Pbs.
11. a. Pawo Pbs = Transrespiratory pressure (PTR), which is the pressure required to inflate the
lungs during positive pressure ventilation.
b. Palv Pbs = Transthoracic pressure (PW or PTT), which is the pressure needed to expand or
contract the lungs and chest wall at the same time.
c. Palv Ppl = Transpulmonary pressure (PL or PTP), which is the pressure required to maintain
alveolar inflation.
d. Pawo Palv = Transairway pressure (PTA), which is the pressure required to produce airflow in
the conductive airways.
12.

13. Negative-pressure ventilation (NPV) attempts to mimic the function of the respiratory
muscles to allow breathing through normal physiological mechanisms. A good example of

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negative pressure ventilators is the tank ventilator, or “iron lung.” With this device, the
patient's head and neck are exposed to ambient pressure while the thorax and the rest of the
body are enclosed in an airtight container that is subjected to negative pressure (i.e., pressure
less than atmospheric pressure). Negative pressure generated around the thoracic area is
transmitted across the chest wall, into the intrapleural space, and finally into the intraalveolar
space.
With negative pressure ventilators, as the intrapleural space becomes negative, the space
inside the alveoli becomes increasingly negative in relation to the pressure at the airway
opening (atmospheric pressure). This pressure gradient results in the movement of air into the
lungs. In this way, negative pressure ventilators resemble normal lung mechanics. Expiration
occurs when the negative pressure around the chest wall is removed. The normal elastic
recoil of the lungs and chest wall causes air to flow out of the lungs passively.
14. Advantages of using negative pressure ventilators include (a) The upper airway can be
maintained without the use of an endotracheal tube or tracheostomy; (b) Patients receiving
negative pressure ventilation can talk and eat while being ventilated; and (c) this mode has
fewer physiologic disadvantages in patients with normal cardiovascular function than does
positive pressure ventilation.
15. Transairway pressure (PTA) = Mouth pressure (PM) alveolus pressure (Palv): 25 cm H2O 5
cm H2O = 20 cm H2O.
16.

17.

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18. Peak inspiratory pressure, peak airway pressure.
19. Baseline pressure.
20. Positive end expiratory pressure.
21. Plateau pressure, selecting inspiratory pause or inflation hold maneuver.
22 Elastic, frictional forces.
23. Compliance, elastance.
24. Change in volume that corresponds to the change in pressure, C = ∆V ÷ ∆P.
25. 0.1 L/cm H2O or 100 mL/cm H2O, 0.05-0.17 L/cm H2O.
26. 40-50 mL/cm H2O, 35 45 mL/cm H2O.
27. CSTAT = ∆V ÷ (Pplat EEP).
28. When more pressure is required to deliver a specific volume, the lung compliance is
decreasing.
29. CS = 750 mL ÷ (27 10 cm H2O) = 44 mL/cm H2O.
30. CS = 575 mL ÷ (35 5 cm H2O) = 19 mL/cm H2O.
31. CS = 650 mL ÷ (18 0 cm H2O) = 36 mL/cm H2O.
32. As the lungs become harder to ventilate, PIP will increase. As the lungs become harder to
ventilate, lung compliance will decrease.
33. Resistance is a measurement of the frictional forces that must be overcome during
breathing.
34. Raw = (PIP Pplat) ÷ Flow (L/sec).
35. At flow rates of 0.5 L/sec, Raw is 0.6-2.4 cm H2O/L/sec.
36. Emphysema can cause increased compliance due to tissue destruction and loss of elastic
recoil. It also can cause airway resistance due to airway inflammation, small airway
obstruction, and bronchospasm.
37. PTA = PIP − Pplat 27 cm H2O 20 cm H2O = 7 cm H2O.
38. The amount of pressure needed to overcome airway resistance or the amount of pressure
lost to airway resistance is equal to the transairway pressure. PTA = 30 cm H2O 20 cm H2O
= 10 cm H2O.
39. 5-7 cm H2O.
40. Raw = (PIP Pplat) ÷ Flow (L/sec)
= (48 30 cm H2O) ÷ (40 L ÷ 60 sec)
= 18 cm H2O ÷ 0.67 L/sec
Raw = 27 cm H2O/L/sec, this is an extremely high Raw.

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 41. Flow rate of 60 L/min = 1 L/sec; Raw = (25 15 cm H2O) ÷ 1 L/sec
Raw = 10 cm H2O/L/sec.
42. Regional differences in compliance and resistance exist throughout the lungs. That is, the
compliance and resistance values of a terminal respiratory unit may be considerably different
from those of another unit.
43. A low compliance unit, because it is stiff, receives less volume than a normal unit;
however, it fills and empties more rapidly than the normal unit. A unit with high airway
resistance fills slowly and takes longer to empty than a normal lung unit. The faster the
respiratory rate, the less volume enters a unit with high airway resistance.
44. The movement of structures, including the lungs, abdominal organs, rib cage, and
diaphragm; gas viscosity; gas density; the length and diameter of the airways; and the flow
rate of the gas are all factors that contribute to airway resistance.
45. Clinical factors that contribute to airway resistance include bronchospasm, airway
secretions, mucosal edema, small endotracheal tubes, and airway inflammation.
46. CS × Raw = Time constant; 25 mL/cm H2O = 0.025 L/cm H2O; 0.025 L/cm H2O × 30 cm
H2O/L/sec = 0.75 sec.
47. Step 1: Calculate CS. CS = 0.6 L ÷ 24 cm H2O = 0.025 L/cm H2O.
Step 2: Calculate Raw. First convert L/min to L/sec. 60 L/min = 1 L/sec.
Then calculate the resistance, Raw = (30 24 cm H2O) ÷ 1 L/sec = 6 cm H2O/L/sec.
Step 3: The product of Raw and CS is the time constant. 6 cm H2O/L/sec × 0.025 L/cm H2O =
0.15 seconds. The time constant is 0.15 seconds.
48. 1—63%, 2—86%, 3—95%, 4—98%, 5—100%.
49. The time constant for patient 1 is very short, meaning that this patient’s lungs are
noncompliant, or stiff. Patient 1 would receive less volume than normal lungs. The time
constant for patient 2 is very long, meaning that there is increased airway resistance. This
patient’s lungs will fill very slowly and receive less volume than normal lungs unless slower
rates are used. Patient 3 has a normal time constant; this patient’s lungs will receive the most
volume of the three patients.
50. 0.055 L/cm H2O × 6 cm H2O/L/sec = 0.33 second.
51. The third time constant will have 95% of the volume emptied. Therefore, 0.33 × 3 = 0.99
second.
52. Patients with increased airway resistance have longer time constants. This means that
their lungs take longer to fill and empty. Rapid respiratory rates reduce the expiratory time,
causing gas to remain in the lungs. The patient is unable to exhale fully. This incomplete
emptying of the lungs increases the FRC (air-trapping) and causes auto-PEEP.
53. CS = 0.7 L ÷ (18 5 cm H2O) = 0.054 L/cm H2O
Raw = (45 18 cm H2O) ÷ (60 L ÷ 60 seconds) = 27 cm H2O/L/sec
Time constant = 0.054 L/cm H2O × 27 cm H2O/L/sec = 1.46 seconds.
54. Figure A represents a normal lung unit. Figure B represents a lung unit with increased
airway resistance. Given the same inspiratory time, the unit with increased airway resistance
will receive less volume because it has a longer time constant.
55. Figure A represents a normal lung unit. Figure B represents a lung unit with low
compliance. The low compliance lung unit has a shorter time constant; it therefore will fill
faster, but with less volume, than the normal lung unit.

Critical Thinking Questions

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 1. PIP represents the amount of pressure required to overcome both the resistance
of the airways and the elastic resistance of the alveoli and ventilator circuitry. Therefore, PIP
minus Pplat equals the amount of pressure required to overcome airway resistance; in this
case: 43 18 = 25 cm H2O.
2. Acute respiratory distress syndrome causes lung compliance to decrease,
which shortens time constants.
3. Emphysema is characterized by dilation and destruction of lung units from the
terminal bronchioles to the alveoli. This tissue destruction causes a loss of elastic recoil,
thereby increasing lung compliance. This lengthens the fill and empty time, which is
represented by a long time constant.
4. At 30 weeks of gestation, there is a high risk for developing respiratory distress
syndrome because of pulmonary immaturity. Insufficient pulmonary surfactant production
leads to low lung compliance and thus short time constants.
5. If you have a patient actively breathing during the plateau pressure measurement, the
reading will be inaccurate. If the patient is actively trying to exhale against the machines
breath hold, coughing, or gagging, the manometer reading may be falsely elevated.

Case Studies

Case Study 1

1. PIP Pplat = Pressure required to overcome airway resistance (PTA)

Time PIP Pplat PTA

0800 18 cm H2O 10 cm H2O 8 cm H2O
1000 24 cm H2O 12 cm H2O 12 cm H2O
1200 35 cm H2O 11 cm H2O 24 cm H2O

2. Raw = PTA ÷ Flow (L/sec)

Time PTA Flow (L/sec) PTA ÷ Flow = Raw

0800 8 cm H2O 45 L ÷ 60 sec = 0.75 L/sec 8 ÷ 0.75 = 10.7 cm H2O/L/sec
1000 12 cm H2O 45 L ÷ 60 sec = 0.75 L/sec 12 ÷ 0.75 = 16 cm H2O/L/sec
1200 24 cm H2O 45 L ÷ 60 sec = 0.75 L/sec 24 ÷ 0.75 = 32 cm H2O/L/sec

3. CSTAT = VT ÷ (Pplat PEEP)

Time VT Pplat PEEP CSTAT

0800 600 mL 10 cm H2O 5 cm H2O 600 mL ÷ 5 cm H2O
= 5 cm H2O = 120 mL/cm H2O
1000 600 mL 12 cm H2O 5 cm H2O 600 mL ÷ 7 cm H2O
= 7 cm H2O = 85.7 mL/cm H2O
1200 600 mL 11 cm H2O 5 cm H2O 600 mL ÷ 6 cm H2O
= 6 cm H2O = 100 mL/cm H2O

4. Time constant = Raw × CSTAT

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Time Raw CSTAT Time Constant
0800 10.7 cm H2O/L/sec 120 mL/cm H2O 1.28 seconds
1000 16 cm H2O/L/sec 85.7 mL/cm H2O 1.37 seconds
1200 32 cm H2O/L/sec 100 mL/cm H2O 3.20 seconds

5. There is a significant rise in both the transairway pressure and the airway
resistance, from 0800 to 1200, along with an increased time constant. This is a clinical
manifestation and indication of bronchospasm, increased secretions, or inflammation.
Because a single time constant has increased to 3.2 seconds, there will be inadequate time for
inspiration and expiration to occur. Therefore, until this situation is corrected, air trapping or
auto-PEEP is very likely.

Case Study 2

1. 40 L/min = 40 L ÷ 60 seconds = 0.67 L/sec; 60 L/min = 1 L/sec

Time PTA Raw CSTAT Time

Constant
1000 40 28 12 cm H2O ÷ 0.67 L/sec 0.550 L ÷ (28 0) 17.9 × 0.0196
= 12 cm H2O = 17.9 cm H2O/L/sec = 0.0196 L/cm H2O = 0.35
seconds
1200 47 37 10 cm H2O ÷ 0.67 L/sec 0.550 L ÷ (37 5) 14.9 × 0.0172
= 10 cm H2O = 14.9 cm H2O/L/sec = 0.0172 L/cm H2O = 0.26 seconds
1400 54 43 11 cm H2O ÷ 0.67 L/sec 0.550 L ÷ (43 7) 16.4 × 0.0153
= 11 cm H2O = 16.4 cm H2O/L/sec = 0.0153 L/cm H2O = 0.25 seconds
1600 55 33 12 cm H2O ÷ 1 L/ sec 0.550 L ÷ (33 12) 12 × 0.0214
= 12 cm H2O = 12 cm H2O/L/sec = 0.0214 L/cm H2O = 0.26 seconds

2. The rising PIP between 1000 and 1400 hours is due to a decrease in static
compliance. The decrease in compliance is due to a rise in plateau pressure from 28 cm H 2O
at 1000 hours to 37 cm H2O at 1200 hours to 43 cm H2O at 1400 hours. This rise
demonstrates stiffening of the lungs. The plateau pressure, and therefore static compliance,
dropped at 1600 hours.
3. Minimum inspiratory time should be three time constants, which correspond to
95% filling of the lungs. Therefore, at 1600 hours the inspiratory time should be 0.26 seconds
× 3 = 0.78 seconds.

NBRC-Style Questions

1. C
2. C
3. D
4. B
5. A
6. A

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7. D
8. C
9. C
10. B

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