copyright © 2006 by mosby, inc. slide 1 section iii the therapist-driven protocol program— the...

Copyright © 2006 by Mosby, Inc.Slide 1

Section IIISection III

The The Therapist-Driven Protocol Program—Therapist-Driven Protocol Program—

The EssentialsThe Essentials


Chapter 9Chapter 9

The Therapist-Driven Protocol The Therapist-Driven Protocol Program and the Role of the Program and the Role of the Respiratory Care PractitionerRespiratory Care Practitioner


Therapist-Driven Protocols Therapist-Driven Protocols (TDPs) Are an Integral Part of (TDPs) Are an Integral Part of

Respiratory Care Health ServicesRespiratory Care Health Services


The Purpose of TDPsThe Purpose of TDPs

Deliver individualized diagnostic and Deliver individualized diagnostic and therapeutic respiratory to patientstherapeutic respiratory to patients

Assist the physician with evaluating patients’ Assist the physician with evaluating patients’ respiratory care needs and to optimize the respiratory care needs and to optimize the allocation of respiratory care servicesallocation of respiratory care services


The Purpose of TDPsThe Purpose of TDPs

Determine the indications for respiratory Determine the indications for respiratory therapy and the appropriate modalities for therapy and the appropriate modalities for providing quality, cost-effective care that providing quality, cost-effective care that improves patient outcomes and decreases improves patient outcomes and decreases length of staylength of stay

Empower respiratory care practitioners to Empower respiratory care practitioners to allocate care using sign- and symptom-based allocate care using sign- and symptom-based algorithms for respiratory treatmentalgorithms for respiratory treatment


Respiratory TDPsRespiratory TDPs

Give practitioner authority to:Give practitioner authority to:

Gather clinical information related to the Gather clinical information related to the patient’s respiratory statuspatient’s respiratory status

Make an assessment of the clinical data Make an assessment of the clinical data collectedcollected

Start, increase, decrease, or discontinue Start, increase, decrease, or discontinue certain respiratory therapies on a moment-certain respiratory therapies on a moment-to-moment basisto-moment basis


The Innate Beauty of Respiratory The Innate Beauty of Respiratory TDPs Is That:TDPs Is That:

1.1. The physician is always in the “information The physician is always in the “information loop” regarding patient careloop” regarding patient care

2.2. Therapy can be quickly modified in response Therapy can be quickly modified in response to the specific and immediate needs of the to the specific and immediate needs of the patientpatient


Clinical Research VerifiesClinical Research VerifiesThese FactsThese Facts

Respiratory TDPsRespiratory TDPs

1.1. Significantly improve respiratory therapy Significantly improve respiratory therapy outcomes, andoutcomes, and

2.2. Appreciably lower therapy costsAppreciably lower therapy costs


Figure 9-1. The promise of a good TDP program.Figure 9-1. The promise of a good TDP program.


Figure 9-2. Figure 9-2. No Assessment Program in Place.No Assessment Program in Place.


The Knowledge Base Required for a The Knowledge Base Required for a Successful TDP ProgramSuccessful TDP Program

The essential knowledge base includes the:The essential knowledge base includes the:

Anatomic alterations of the lungsAnatomic alterations of the lungs

Pathophysiologic mechanisms activatedPathophysiologic mechanisms activated

Clinical manifestations that developClinical manifestations that develop

Treatment modalities used to correct the Treatment modalities used to correct the problemproblem


Figure 9-3. Foundations for a strong TDP program. Overview of the Figure 9-3. Foundations for a strong TDP program. Overview of the essential knowledge base for assessment of respiratory diseases. essential knowledge base for assessment of respiratory diseases.


The Assessment Process Skills Required The Assessment Process Skills Required for a Successful TDP Programfor a Successful TDP Program

The practitioner must: The practitioner must:

Systematically gather clinical informationSystematically gather clinical information

Formulate an assessmentFormulate an assessment

Select an optimal treatmentSelect an optimal treatment

Document in a clear and precise mannerDocument in a clear and precise manner


Figure 9-4. Figure 9-4. The way knowledge, assessment, and a TDP program interface.The way knowledge, assessment, and a TDP program interface.


Common Respiratory Assessments—Common Respiratory Assessments—Excerpts (see Table 9-1)Excerpts (see Table 9-1)

Clinical DataClinical Data AssessmentAssessment

WheezingWheezing BronchospasmBronchospasm

RhonchiRhonchi Secretions in large airwaysSecretions in large airways

Weak coughWeak cough Poor ability to mobilize Poor ability to mobilize secretionssecretions

ABGsABGs Acute ventilatory failureAcute ventilatory failure pHpH 7.24 7.24 PaPaCOCO22 73 73

HCOHCO33-- 27 27

PaPaOO22 5353


Severity AssessmentSeverity Assessment


Table 9-2. Respiratory Care Protocol Table 9-2. Respiratory Care Protocol Severity Assessment—Severity Assessment—ExcerptsExcerpts

ItemItem 0 point0 point 1 point1 point 2 points2 points 3 points3 points 4 points4 points Total PointsTotal Points

Breath soundsBreath sounds ClearClear BilateralBilateral BilateralBilateral BilateralBilateral Absent and/orAbsent and/or ____________

cracklescrackles cracklescrackles wheezing,wheezing, diminishdiminish

& rhonchi& rhonchi crackles &crackles & bilateral and/orbilateral and/or

rhonchirhonchi severe wheezing,severe wheezing,

crackles, orcrackles, or

rhonchirhonchi

CoughCough Strong,Strong, ExcessiveExcessive ExcessiveExcessive ThickThick ThickThick ____________

spontaneous,spontaneous, bronchialbronchial bronchialbronchial bronchialbronchial bronchialbronchial

nonproductivenonproductive secretions &secretions & secretions butsecretions but secretions &secretions & secretions butsecretions but

strong coughstrong cough weak coughweak cough weak coughweak cough no coughno cough


Severity Assessment Case ExampleSeverity Assessment Case ExampleSEVERITY ASSESSMENT CASE EXAMPLESEVERITY ASSESSMENT CASE EXAMPLE

A 67-YEAR-OLD-MALE ARRIVED IN THE EMERGENCY ROOM IN RESPIRATORY DISTRESS. THE PATIENT WAS A 67-YEAR-OLD-MALE ARRIVED IN THE EMERGENCY ROOM IN RESPIRATORY DISTRESS. THE PATIENT WAS

WELL KNOWN TO THE TDP TEAM; HE HAD BEEN DIAGNOSED WITH CHRONIC BRONCHITIS SEVERAL WELL KNOWN TO THE TDP TEAM; HE HAD BEEN DIAGNOSED WITH CHRONIC BRONCHITIS SEVERAL

YEARS BEFORE THIS ADMISSIONYEARS BEFORE THIS ADMISSION (3 POINTS)(3 POINTS). THE PATIENT HAD NO RECENT SURGERY HISTORY, AND HE . THE PATIENT HAD NO RECENT SURGERY HISTORY, AND HE

WAS AMBULATORY, ALERT, AND COOPERATIVEWAS AMBULATORY, ALERT, AND COOPERATIVE (0 POINTS)(0 POINTS).. HE COMPLAINED OF DYSPNEA AND WAS HE COMPLAINED OF DYSPNEA AND WAS

USING HIS ACCESSORY MUSCLES OF INSPIRATIONUSING HIS ACCESSORY MUSCLES OF INSPIRATION (3 POINTS).(3 POINTS). AUSCULTATION REVEALED BILATERAL AUSCULTATION REVEALED BILATERAL

RHONCHI OVER BOTH LUNG FIELDSRHONCHI OVER BOTH LUNG FIELDS (3 POINTS)(3 POINTS). HIS COUGH WAS WEAK AND PRODUCTIVE OF THICK . HIS COUGH WAS WEAK AND PRODUCTIVE OF THICK

GRAY SECRETIONSGRAY SECRETIONS (3 POINTS)(3 POINTS).. A CHEST RADIOGRAPH REVEALED PNEUMONIA (CONSOLIDATION) IN THE A CHEST RADIOGRAPH REVEALED PNEUMONIA (CONSOLIDATION) IN THE

LEFT LOWER LUNG LOBELEFT LOWER LUNG LOBE (3 POINTS)(3 POINTS).. ON ROOM AIR HIS ARTERIAL BLOOD GAS VALUES WERE pH 7.52, ON ROOM AIR HIS ARTERIAL BLOOD GAS VALUES WERE pH 7.52,

PaPaCOCO22 54, HCO 54, HCO33-- 41, AND Pa 41, AND PaOO22 52—ACUTE ALVEOLAR HYPERVENTILATION ON CHRONIC VENTILATORY 52—ACUTE ALVEOLAR HYPERVENTILATION ON CHRONIC VENTILATORY

FAILUREFAILURE (3 POINTS)(3 POINTS)..

USING THE SEVERITY ASSESSMENT FORM SHOWN IN TABLE 9-2, THE FOLLOWING TREATMENT SELECTION USING THE SEVERITY ASSESSMENT FORM SHOWN IN TABLE 9-2, THE FOLLOWING TREATMENT SELECTION

AND ADMINISTRATION FREQUENCY WOULD BE APPROPRIATE: AND ADMINISTRATION FREQUENCY WOULD BE APPROPRIATE:

TOTAL SCORE:TOTAL SCORE: 1717

TREATMENT SELECTION:TREATMENT SELECTION: CHEST PHYSICAL THERAPYCHEST PHYSICAL THERAPY

FREQUENCY OF ADMINISTRATION:FREQUENCY OF ADMINISTRATION: FOUR TIMES A DAY; AS NEEDEDFOUR TIMES A DAY; AS NEEDED


The Top Four Respiratory ProtocolsThe Top Four Respiratory Protocols

Oxygen therapy protocolOxygen therapy protocol

Bronchopulmonary hygiene therapy protocolBronchopulmonary hygiene therapy protocol

Hyperinflation therapy protocolHyperinflation therapy protocol

Aerosolized medication therapy protocolAerosolized medication therapy protocol


Common Respiratory Assessments Common Respiratory Assessments and Treatment Plans—Excerpts (see and Treatment Plans—Excerpts (see

Table 9-1)Table 9-1)

Clinical DataClinical Data AssessmentAssessment Tx PlanTx Plan

WheezingWheezing BronchospasmBronchospasm betabeta22 agent agent

Rhonchi &Rhonchi & Secretions in large airwaysSecretions in large airwaysWeak coughWeak cough Poor ability to mobilize secretionsPoor ability to mobilize secretions CPTCPT

ABGsABGs Acute ventilatory failureAcute ventilatory failure Mechanical ventilationMechanical ventilation

pHpH7.24 7.24

PaPaCOCO22 73 73

HCOHCO33-- 27 27

PaPaOO22 5353


Oxygen Therapy Oxygen Therapy Protocol 9-1Protocol 9-1


Oxygen Therapy Oxygen Therapy Protocol 9-1—Protocol 9-1—

Close-upsClose-ups


Common Common Oxygen Therapy SelectionsOxygen Therapy Selections

Nasal cannulaNasal cannula

Oxygen maskOxygen mask

Venturi maskVenturi mask

Partial rebreathing maskPartial rebreathing mask

Nonrebreathing maskNonrebreathing mask


Bronchopulmonary Bronchopulmonary Hygiene Therapy Hygiene Therapy

Protocol 9-2Protocol 9-2


Bronchopulmonary Hygiene Bronchopulmonary Hygiene Therapy Protocol 9-2— Therapy Protocol 9-2—

Close-upsClose-ups


Common Bronchopulmonary Common Bronchopulmonary Hygiene Therapy SelectionsHygiene Therapy Selections

Increased fluid intakeIncreased fluid intake

Cough and deep breatheCough and deep breathe

Chest physical therapyChest physical therapy

SuctioningSuctioning

Bronchoscopy assistBronchoscopy assist

Mucolytic aerosolMucolytic aerosol


Hyperinflation TherapyHyperinflation TherapyProtocol 9-3 Protocol 9-3

(Lung Expansion Protocol)(Lung Expansion Protocol)


Hyperinflation TherapyHyperinflation TherapyProtocol 9-3Protocol 9-3

(Lung Expansion Protocol)—(Lung Expansion Protocol)—Close-upsClose-ups


Common Common Hyperinflation Therapy SelectionsHyperinflation Therapy Selections

Cough and deep breatheCough and deep breathe

Incentive spirometryIncentive spirometry

IPPBIPPB

CPAPCPAP

PEEP PEEP


Aerosolized Medication Therapy Aerosolized Medication Therapy Protocol 9-4Protocol 9-4


Aerosolized Medication Therapy Aerosolized Medication Therapy Protocol 9-4—Protocol 9-4—

Close-upsClose-ups


Common Aerosolized Medication Common Aerosolized Medication SelectionsSelections

Bronchodilator agentsBronchodilator agents SympathomimeticsSympathomimetics

ParasympatholyticsParasympatholytics

Mucolytic agentsMucolytic agents

Antiinflammatory agentsAntiinflammatory agents

Antibiotic agentsAntibiotic agents


Mechanical VentilationMechanical VentilationProtocol 9-5Protocol 9-5


Mechanical VentilationMechanical VentilationProtocol 9-5— Protocol 9-5—

Close-upsClose-ups


Disorder: Normal Lung Mechanics Disorder: Normal Lung Mechanics but Patient Has Apneabut Patient Has Apnea

Disease characteristicsDisease characteristics Normal compliance and airway resistanceNormal compliance and airway resistance

Ventilator modeVentilator mode Volume ventilation in the AC or SIMV modeVolume ventilation in the AC or SIMV mode

Or pressure ventilation—either PRVC or PCOr pressure ventilation—either PRVC or PC

Tidal volume and respiratory rateTidal volume and respiratory rate 10 to 12 ml/kg10 to 12 ml/kg

6 to 10 bpm6 to 10 bpm

• to 10 bpm when SIMV mode is usedto 10 bpm when SIMV mode is used

Table 9-3. Common Ventilatory Management StrategiesTable 9-3. Common Ventilatory Management Strategies


Normal Lung Mechanics, cont.Normal Lung Mechanics, cont.

Flow rateFlow rate 60 to 80 L/min60 to 80 L/min

I:E ratioI:E ratio 1:21:2

FIFIOO22

Low to moderateLow to moderate

General goals and/or concernsGeneral goals and/or concerns Care to ensure plateau pressure of 30 cm HCare to ensure plateau pressure of 30 cm H22O or lessO or less

Smaller tidal volumes (<7 ml/kg) should be avoided because Smaller tidal volumes (<7 ml/kg) should be avoided because atelectasis can developatelectasis can develop

Table 9-3. Common Ventilatory Management Strategies, Table 9-3. Common Ventilatory Management Strategies, cont.cont.


Disorder: Chronic Obstructive Disorder: Chronic Obstructive Pulmonary Disease (COPD)Pulmonary Disease (COPD)

Disease characteristicsDisease characteristics High lung compliance and high airway resistanceHigh lung compliance and high airway resistance



Noninvasive positive pressure ventilation (NPPV) is good Noninvasive positive pressure ventilation (NPPV) is good alternativealternative

Tidal volume and respiratory rateTidal volume and respiratory rate Good starting point: 10 ml/kg and 10 to12 bpmGood starting point: 10 ml/kg and 10 to12 bpm

A small tidal volume (8-10 ml/kg) and 8 to 10 bpm with A small tidal volume (8-10 ml/kg) and 8 to 10 bpm with increased flow rates to allow adequate expiratory timeincreased flow rates to allow adequate expiratory time



COPD, cont.COPD, cont. Flow rateFlow rate

60 L/min60 L/min

I:E ratioI:E ratio 1:2 or 1:31:2 or 1:3

FIFIOO22


General goals and/or concernsGeneral goals and/or concerns Air-trapping and auto-PEEP can occur when expiratory time is too Air-trapping and auto-PEEP can occur when expiratory time is too

shortshort ↑ ↑ Expiratory time to offset auto-PEEPExpiratory time to offset auto-PEEP May ↑ inspiratory flow up to 100 L/min to ↑ expiratory timeMay ↑ inspiratory flow up to 100 L/min to ↑ expiratory time May ↓ VT or rate to ↑ expiratory timeMay ↓ VT or rate to ↑ expiratory time Do not overventilate COPD patients with chronically high PaDo not overventilate COPD patients with chronically high PaCOCO22 levels levels



Disorder: Acute Asthmatic EpisodeDisorder: Acute Asthmatic Episode

Disease characteristicsDisease characteristics High airway resistanceHigh airway resistance

Ventilator modeVentilator mode SIMV mode is recommended to offset air-trappingSIMV mode is recommended to offset air-trapping

Tidal volume and respiratory rateTidal volume and respiratory rate Good starting point: 8 to 10 ml/kg Good starting point: 8 to 10 ml/kg

Rate of 10 to 12 bpmRate of 10 to 12 bpm

When air-trapping is extensive, a lower tidal volumeWhen air-trapping is extensive, a lower tidal volume(5-6 ml/kg) and slower rate may be required(5-6 ml/kg) and slower rate may be required



Acute Asthmatic Episode, cont.Acute Asthmatic Episode, cont. Flow rateFlow rate

60 L/min60 L/min

I:E ratioI:E ratio 1:2 or 1:31:2 or 1:3

FIFIOO22

Start at 100% and titrate downward per SpStart at 100% and titrate downward per SpOO22 and ABGs and ABGs

General goals and/or concernsGeneral goals and/or concerns In severe cases, the development of auto-PEEP may be In severe cases, the development of auto-PEEP may be

inevitable inevitable

With controlled ventilation, a small amount of PEEP to offset With controlled ventilation, a small amount of PEEP to offset auto-PEEP may be cautiously appliedauto-PEEP may be cautiously applied



Disorder: Acute Respiratory Distress Disorder: Acute Respiratory Distress SyndromeSyndrome

Disease characteristicsDisease characteristics Diffuse, uneven alveolar injuryDiffuse, uneven alveolar injury


Or pressure ventilation—PRVC or PCOr pressure ventilation—PRVC or PC

Tidal volume and respiratory rateTidal volume and respiratory rate Typically, started at low tidal volumes and higher ratesTypically, started at low tidal volumes and higher rates

• 8 mL/kg and adjusted downward to 6 ml/kg; or 4 ml/kg8 mL/kg and adjusted downward to 6 ml/kg; or 4 ml/kg

• Respiratory rate as high as 35 bpmRespiratory rate as high as 35 bpm



Acute Respiratory Distress Acute Respiratory Distress Syndrome, cont.Syndrome, cont.

Flow rateFlow rate 60 to 80 L/min60 to 80 L/min

I:E ratioI:E ratio 1:1 or 1:21:1 or 1:2 Do what is necessary to meet a rapid respiratory rateDo what is necessary to meet a rapid respiratory rate

FIFIOO22 Less than 0.6 if possibleLess than 0.6 if possible

General goals and/or concernsGeneral goals and/or concerns Goal is to limit transpulmonary pressuresGoal is to limit transpulmonary pressures 30 cm H30 cm H22O or less if possibleO or less if possible PEEP is usually needed to prevent atelectasisPEEP is usually needed to prevent atelectasis Permissive hypercapnia may be allowed Permissive hypercapnia may be allowed



Disorder: Postoperative Ventilatory Disorder: Postoperative Ventilatory SupportSupport

Disease characteristicsDisease characteristics Often normal compliance and airway resistanceOften normal compliance and airway resistance

Ventilator modeVentilator mode SIMV with pressure support SIMV with pressure support Or AC volume ventilationOr AC volume ventilation Or pressure ventilation—either PRVC for PCOr pressure ventilation—either PRVC for PC

Tidal volume and respiratory rateTidal volume and respiratory rate Good starting point: 10 to 12 ml/kgGood starting point: 10 to 12 ml/kg Rate of 10 to 12 bpmRate of 10 to 12 bpm

• However, larger tidal volumes (12-15 ml/kg) and slower rates However, larger tidal volumes (12-15 ml/kg) and slower rates (6-10 bpm) may be used to maintain lung volume(6-10 bpm) may be used to maintain lung volume



Postoperative Ventilatory Support, Postoperative Ventilatory Support, cont.cont.

Flow rateFlow rate 60 L/min60 L/min


FIFIOO22


General goals and/or concernsGeneral goals and/or concerns

PEEP or CPAP of 3 to 5 cm HPEEP or CPAP of 3 to 5 cm H22O may be applied O may be applied

to offset atelectasisto offset atelectasis



Disorder: Neuromuscular DisorderDisorder: Neuromuscular Disorder

Disease characteristicsDisease characteristics Normal compliance and airway resistanceNormal compliance and airway resistance



Tidal volume and respiratory rateTidal volume and respiratory rate Good starting point: 12 to 15 ml/kgGood starting point: 12 to 15 ml/kg

Rate of 10 to 12 bpmRate of 10 to 12 bpm



Neuromuscular Disorder, cont.Neuromuscular Disorder, cont.

Flow rateFlow rate 60 L/min60 L/min


FIFIOO22


General goals and/or concernsGeneral goals and/or concerns PEEP of 3 to 5 cm HPEEP of 3 to 5 cm H22O may be applied to O may be applied to

offset atelectasisoffset atelectasis



Overview Summary of a Good Overview Summary of a Good TDP ProgramTDP Program


Figure 9-5. Figure 9-5. Overview of the essential components of a good TDP program.Overview of the essential components of a good TDP program.


Figure 9-5. Close-up.Figure 9-5. Close-up.


Figure 9-5. Figure 9-5. Overview of the essential components of a good TDP program.Overview of the essential components of a good TDP program.


Figure 9-6Figure 9-6Respiratory Care Protocol Respiratory Care Protocol

Program Assessment Form— Program Assessment Form— ExcerptsExcerpts


Oxygen TherapyOxygen Therapy

Clinical IndicatorsClinical Indicators

HistoryHistory

SpSpOO22 <80% <80%

PaPaOO22 <60 mm Hg <60 mm Hg

Acute hypoxemiaAcute hypoxemia ↑ ↑ Respiratory rateRespiratory rate

↑ ↑ PulsePulse

CyanosisCyanosis

ConfusionConfusion

Figure 9-6. Respiratory care protocol program assessment formFigure 9-6. Respiratory care protocol program assessment form—Example Excerpts—Example Excerpts


Respiratory AssessmentRespiratory Assessment

ExamplesExamples

Mild hypoxemiaMild hypoxemia

Moderate hypoxemiaModerate hypoxemia

Severe hypoxemiaSevere hypoxemia

Severity score: __________Severity score: __________

Figure 9-6. Respiratory care protocol program assessment form—Figure 9-6. Respiratory care protocol program assessment form—ExampleExample excerpts. excerpts.


Treatment PlanTreatment Plan

Oxygen TherapyOxygen Therapy

Examples:Examples:

Nasal cannulaNasal cannula

Oxygen maskOxygen mask

28% Venturi mask28% Venturi mask

Frequency: _______________Frequency: _______________

Figure 9-6. Respiratory care protocol program assessment form—Figure 9-6. Respiratory care protocol program assessment form—ExampleExample excerpts. excerpts.


Common Anatomic AlterationsCommon Anatomic Alterationsof the Lungsof the Lungs

AtelectasisAtelectasis

Alveolar consolidationAlveolar consolidation

↑ ↑ Alveolar-capillary membrane thicknessAlveolar-capillary membrane thickness

BronchospasmBronchospasm

Excessive bronchial secretionsExcessive bronchial secretions

Distal airway and alveolar weakeningDistal airway and alveolar weakening


Box 9-2. PathophysiologicBox 9-2. PathophysiologicMechanisms Commonly Mechanisms Commonly

ActivatedActivatedin Respiratory Disordersin Respiratory Disorders

Decreased V/Q ratioDecreased V/Q ratio

Alveolar diffusion blockAlveolar diffusion block

Decreased lung complianceDecreased lung compliance

Stimulation of oxygen receptorsStimulation of oxygen receptors

Deflation reflexDeflation reflex

Irritant reflexIrritant reflex

Pulmonary reflexPulmonary reflex

Increased airway resistanceIncreased airway resistance

Air-trapping and alveolar hyperinflationAir-trapping and alveolar hyperinflation(See clinical scenarios.)(See clinical scenarios.)


Clinical Scenarios Clinical Scenarios Activated by the Common Anatomic Activated by the Common Anatomic

Alterations of the LungsAlterations of the Lungs


Atelectasis Atelectasis Clinical ScenarioClinical Scenario


Figure 9-7. Atelectasis clinical scenario. Figure 9-7. Atelectasis clinical scenario.


Figure 9-7. Atelectasis—close-ups.Figure 9-7. Atelectasis—close-ups.


Figure 9-7. Atelectasis clinical scenario—close-ups.Figure 9-7. Atelectasis clinical scenario—close-ups.


Figure 9-7. Atelectasis clinical scenario.Figure 9-7. Atelectasis clinical scenario.


Alveolar ConsolidationAlveolar Consolidation Clinical Scenario Clinical Scenario


Figure 9-8. Alveolar consolidation clinical scenario.Figure 9-8. Alveolar consolidation clinical scenario.


Figure 9-8. Alveolar consolidation clinical scenario (e.g., pneumonia)—close-ups.Figure 9-8. Alveolar consolidation clinical scenario (e.g., pneumonia)—close-ups.


Figure 9-8. Alveolar consolidation clinical scenario—close-ups.Figure 9-8. Alveolar consolidation clinical scenario—close-ups.


Figure 9-8. Alveolar consolidation clinical scenario.Figure 9-8. Alveolar consolidation clinical scenario.


Increased Alveolar-Capillary Increased Alveolar-Capillary Membrane ThicknessMembrane Thickness

Clinical ScenarioClinical Scenario


Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario.Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario.


Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario (e.g., ARDS)—close-ups.Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario (e.g., ARDS)—close-ups.


Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario—close-ups.Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario—close-ups.


Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario.Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario.


BronchospasmBronchospasm Clinical Scenario Clinical Scenario


Figure 9-10. Bronchospasm clinical scenario (e.g., asthma). Figure 9-10. Bronchospasm clinical scenario (e.g., asthma).


Figure 9-10. Bronchospasm clinical scenario (e.g., asthma)—close-ups.Figure 9-10. Bronchospasm clinical scenario (e.g., asthma)—close-ups.


Figure 9-10. Bronchospasm clinical scenario (e.g., asthma).Figure 9-10. Bronchospasm clinical scenario (e.g., asthma).


Excessive Bronchial SecretionsExcessive Bronchial Secretions Clinical Scenario Clinical Scenario


Figure 9-11. Excessive bronchial secretions clinical scenario. Figure 9-11. Excessive bronchial secretions clinical scenario.


Figure 9-11. Excessive bronchial secretions clinical scenario—close-ups.Figure 9-11. Excessive bronchial secretions clinical scenario—close-ups.


Figure 9-11. Excessive bronchial secretions clinical scenario.Figure 9-11. Excessive bronchial secretions clinical scenario.


Distal Airway andDistal Airway andAlveolar WeakeningAlveolar Weakening

Clinical Scenario Clinical Scenario


Fig. 9-12 Fig. 9-12 Distal airway and alveolar weakening clinical scenario. Distal airway and alveolar weakening clinical scenario.


Figure 9-12. Distal airway and alveolar weakening clinical scenario—close-ups.Figure 9-12. Distal airway and alveolar weakening clinical scenario—close-ups.


Figure 9-12. Distal airway and alveolar weakening clinical scenario.Figure 9-12. Distal airway and alveolar weakening clinical scenario.


Figure 9-13. A three-component model of a prototype airway.Figure 9-13. A three-component model of a prototype airway.A, Airway lumen; B, airway wall; C, supporting structure. A, Airway lumen; B, airway wall; C, supporting structure.

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