Clinical Manifestations & Assessment of Respiratory Disease
9th Edition
Visit the link below to download the full version of this book:
https://medipdf.com/product/clinical-manifestations-assessment-of-respiratory-di
sease-9th-edition/
Click Download Now
Part XII. Sleep-Related Breathing Disorders
Part XIII. Newborn and Early Childhood Cardiopulmonary
Disorders
Part XIV. Other Important Topics
Copyright
Elsevier
3251 Riverport Lane
St. Louis, Missouri 63043
CLINICAL MANIFESTATIONS AND ASSESSMENT Of
RESPIRATORY DISEASE, NINTH EDITION ISBN: 978-0-323-
87150-1
Copyright © 2024 by Elsevier, Inc. All rights reserved.
Previous editions copyrighted 2020, 2016, 2011, 2006, 2002, 1995,
1990, 1984.
No part of this publication may be reproduced or transmitted in any
form or by any means, electronic or mechanical, including
photocopying, recording, or any information storage and retrieval
system, without permission in writing from the publisher. Details
on how to seek permission, further information about the
Publisher’s permissions policies, and our arrangements with
organizations such as the Copyright Clearance Center and the
Copyright Licensing Agency can be found at our website:
www.elsevier.com/permissions.
This book and the individual contributions contained in it are
protected under copyright by the Publisher (other than as may be
noted herein).
Notice
Practitioners and researchers must always rely on their own
experience and knowledge in evaluating and using any
information, methods, compounds, or experiments described
herein. Because of rapid advances in the medical sciences in
particular, independent verification of diagnoses and drug dosages
should be made. To the fullest extent of the law, no responsibility
is assumed by Elsevier, authors, editors, or contributors for any
injury and/or damage to persons or property as a matter of
products liability, negligence or otherwise, or from any use or
operation of any methods, products, instructions, or ideas
contained in the material herein.
ISBN: 978-0-323-87150-1
Content Strategist: Melissa Rawe
Senior Content Development Manager: Lisa Newton
Senior Content Development Specialist: Laura Selkirk
Book Production Manager: Deena Burgess
Senior Project Manager: Anne Collett
Senior Book Designer: Amy Buxton
Printed in the United States of America
Last digit is the print number: 9 8 7 6 5 4 3 2 1
Dedication
In Memory of Robert M. Kacmarek
and
Our Departed Co-Workers and Patients
This 9 th edition of Clinical Manifestations and Assessment of
Respiratory Diseases is dedicated in part to one of our profession’s
most outstanding leaders, teacher, researcher, clinician and friend,
Robert M. Kacmarek, PhD, RRT, FAARC. 1
In addition, we also wish to remember our professional co-workers
who died or continued to work, and their patients, in the face of the
most devastating pandemic of our time, COVID-19 (see Chapter 18
and Chapter 28 ).
Many of the predictions we made in the lead material of the 8th
edition (2020) have unfortunately come true. The manpower
shortage predicted then is more acute than ever, with early
retirement, deaths, age and worker “burnout” 2 adding to the
problem. Fortunately, some work has progressed on the Advanced
Practitioner Respiratory Therapy (APRT) licensure issue at least in
Ohio 3 , and the concept is gaining traction in other areas of the
country.
The rationales for remediation of the manpower issue proposed by
the Barnes Task Force 4 in 2015 are still absolutely on track –
education is key to the solution of the manpower issue. The
education issue has only been exacerbated by significant new
concepts in respiratory disease diagnosis and treatment since our
last edition (see Introduction). Unfortunately, the achievement of
the required clinical knowledge and clinical training base
underlying these new concepts are both time- and labor-intensive.
As has been the case in the past, our care colleagues in medicine,
nursing, physical therapy, radiology technology, laboratory
technology and other disciplines, have risen to the challenge and
are greatly helpful in the needed education implementation process.
4,5 In addition, the Committee on Respiratory Care Education
(CoARC) and the National Board for Respiratory Care (NBRC)
have been particularly helpful.
Original concerns about the cost-effectiveness of therapist-driven
protocols (TDPs) is being slowly addressed. Periodic Therapy TDP
education and mandatory competency testing, and shift change
errors and other symptoms of burnout are being successfully
addressed. 6 The problems with shortcuts and “peek-a-boo”
physical examinations have been identified and have been dealt
with forcefully.
Meanwhile, the database continues to grow and the need to focus
on pathophysiologic changes is stronger than ever.
1Hess DR (2021). Loss of a legend: remembering Robert M.
Kacmerak. Respiratory Care, 66(6), 1016-1018.
2 Miller, AG, Roberts KJ, Hinkson CR, et al. (2021). Resilience and
burnout resources in respiratory care departments. Respiratory
Care, 66(5), 715-722.
3 Strickland, SL, Varekojis SM, Goodfellow LT, et al. (2020).
Physician support for non-physician advanced practice providers for
persons with cardiopulmonary disease. Respiratory Care, 65(11),
1702-1711.
4 Burr KL, Stump AA, Bladen RC, et al. (2021). Twice daily huddles
improve collaborative problem solving in the respiratory care
department. Respiratory Care, 66(5), 822-828
5Messina A, et al. (2021). Critical care outreach team during
COVID-19: Ventilatory support in the ward and outcomes.
Respiratory Care, 6(6), 928-935.
6Hess DR (2021). Evidence-based respiratory care. Respiratory
Care, 66(7), 1105-1118.
Consultants
Newborn and Early Childhood Respiratory Disorders
Sue Ciarlariello, MBA, RRT-NPS, RCP, CMTE, FAARC ,
Former Director, Respiratory Care and Transport, Dayton Children’s
Hospital, Dayton, Ohio
Quick Response (QR) Code Coordination & Development
Gayle Carr, MS, RRT, CPFT , Retired Adjunct Faculty, Illinois
Central College, East Peoria, Illinois
Radiology & Pulmonary Disease Resource
Dwayne M. Griffin, MD , McLaren Northern Michigan
Hospital, Petoskey, Michigan
Neuromuscular Disease
Gabriel Thornton, MD , Pulmonary and Critical Care
Medicine Fellow, Northwestern Memorial Hospital, Northwestern
Medicine, Chicago, Illinois
Lisa F. Wolfe, MD , Northwestern Medical Group, Pulmonary
Critical Care Medicine, Sleep Medicine, Northwestern Memorial
Hospital, Northwestern MedicineChicago, Illinois
Reviewers
Lisa Fuchs, EdD, MHA, RRT, CTTS, CHWC , Program
Director and Assistant Professor, Respiratory Therapy Program,
Nebraska Methodist College, Omaha, Nebraska
Misty Carson, MS, RRT , Director of Clinical Education,
Daytona State College, Daytona Beach, Florida
Preface
The use of therapist-driven protocols (TDPs)—now often called
simply respiratory protocols—is an integral part of respiratory
health services. TDPs provide much-needed flexibility to respiratory
care practitioners and increase the quality of health care. This is
because the respiratory therapy care program can be modified easily
and efficiently according to the needs of the patient.
Essential cornerstones to the success of a TDP program are (1)
the quality of the respiratory therapist’s assessment skills at the
bedside and (2) the ability to transfer objective clinical data into a
treatment plan that follows agreed-upon guidelines. This textbook is
designed to provide the student with the fundamental knowledge
and understanding necessary to assess and treat patients with
respiratory diseases to meet these objectives. Again, content
updates have made this volume very pertinent to the working
respiratory therapist preparing for the NBRC exams (see New to
the Ninth Edition after this section).
Part I of the textbook, Assessment of Cardiopulmonary Disease,
contains three sections:
Section 1, Bedside Diagnosis, consists of three chapters. Chapter
1 describes the knowledge and skills involved in the patient
interview. Chapter 2 provides the knowledge and skills needed for
the physical examination. Chapter 3 presents a more in-depth
discussion of the pathophysiologic basis for commonly observed
clinical manifestations of respiratory diseases.
Section 2, Clinical Data Obtained From Laboratory Tests and
Special Procedures, is composed of Chapters 4 through 9.
Collectively, these chapters provide the reader with the essential
knowledge and understanding base for the assessment of
pulmonary function studies, arterial blood gases, oxygenation, the
cardiovascular system (including hemodynamic monitoring),
radiologic examination of the chest, and other important laboratory
tests and procedures.
Section 3, The Therapist-Driven Protocol Program—The
Essentials, consists of Chapters 10, 11, and 12.
Chapter 10 , “The Therapist-Driven Protocol Program,” provides
the reader with the essential knowledge base and step-by-step
process needed to assess and implement protocols in the clinical
setting. The student is provided with the basic knowledge and
helpful tools to (1) gather clinical data systematically, (2) formulate
an assessment (i.e., the cause and severity of the patient’s
condition), (3) select an appropriate and cost-effective treatment
plan, and (4) document these essential steps clearly and precisely.
At the end of each respiratory disorder chapter, one or more
representative case studies demonstrate appropriate TDP
assessment, treatment, and charting strategies. Chapter 10 is a
cornerstone chapter of the fundamentals necessary for good
assessment and critical-thinking skills. The case studies presented
at the end of each respiratory disorder chapter often direct the
reader back to Chapter 10.
Chapter 11 , “Respiratory Insufficiency, Respiratory Failure, and
Ventilatory Management Protocols,” is a fully up-dated chapter in
this ninth edition. This chapter describes how respiratory failure
can be classified as (1) hypoxemic (type I) respiratory failure, (2)
hypercapnic (type II) respiratory failure, or (3) a combination of
both. These categories reflect the pathophysiologic basis of
respiratory failure. In addition, this chapter provides the
components of mechanical ventilation protocols, including the
standard criteria for mechanical ventilation, the clinical indicators
for both hypercapnic and hypoxemic respiratory failure, ventilatory
support strategies for noninvasive and invasive mechanical
ventilation, a mechanical ventilator management protocol, and a
mechanical ventilation weaning protocol.
Chapter 12 , “Recording Skills and Intraprofessional
Communication,” provides the basic foundation needed to collect
and record clinical manifestations, respiratory assessments, and
treatment plans.
Parts II through XIV (Chapters 13 through 45) provide the
reader with essential information regarding common respiratory
diseases. Each chapter adheres to the following format: a
description of the anatomic alterations of the lungs, etiology of the
disease process, an overview of the cardiopulmonary clinical
manifestations associated with the disorder, management of the
respiratory disorder, one or more case studies, and a brief set of
self-assessment questions. A further description of this format
follows.
Anatomic Alterations of the Lungs
Each respiratory disease chapter begins with a detailed, color
illustration showing the major anatomic alterations of the lungs
associated with the disorder. Although a serious effort has been
made to illustrate each disorder accurately at the beginning of each
chapter, artistic license (“cartooning”) has been taken to emphasize
certain anatomic points and pathologic processes. When the
anatomic alterations and pathophysiologic mechanisms caused by
the disorder are improved, the clinical manifestations also should
improve. The material that follows this section in each respiratory
disorder chapter discusses the disease in terms of the following:
1. The common pathophysiologic mechanisms activated
throughout the cardiopulmonary system as a result of the
anatomic alterations
2. The clinical manifestations that develop as a result of the
pathophysiologic mechanisms
3. The basic respiratory therapy modalities used to improve the
anatomic alterations and pathophysiologic mechanisms
caused by the disease
Etiology
A discussion of the etiology of the disease under consideration
follows the presentation of anatomic alterations of the lungs.
Various causes, predisposing conditions, and common
comorbidities are described.
Overview of the Cardiopulmonary Clinical
Manifestations Associated With the
Disorder
This section comprises the central theme of the text. The reader is
provided with the clinical manifestations commonly associated with
the disease under discussion. In essence, the student is given a
general “overview” of the signs and symptoms commonly
demonstrated by the patient. By having a working knowledge—and
therefore a predetermined expectation—of the clinical
manifestations associated with a specific respiratory disorder, the
respiratory therapist is in a better position to:
1. Gather clinical data relevant to the patient’s respiratory
status
2. Formulate an objective—and measurable—respiratory
assessment
3. Develop an effective and safe treatment plan that is based on
a valid assessment
If the appropriate data are not gathered and assessed correctly,
the ability to treat the patient effectively is lost. As mentioned
earlier, the case studies presented at the end of each respiratory
disorder chapter frequently refer the reader back to Chapter 10 for a
broader discussion of the signs and symptoms commonly associated
with the disease under discussion—the “clinical scenario.” When a
particular clinical manifestation is unique to the respiratory
disorder, however, a discussion of the pathophysiologic
mechanisms responsible for the signs and symptoms is presented in
the respective chapter.
Because of the dynamic nature of many respiratory disorders, the
reader should note the following regarding this section:
• Because the severity of the disease is influenced by a number
of factors (e.g., the extent of the disease, age, the general
health of the patient), the clinical manifestations may vary
considerably from one patient to another. In fact, they may
often vary in the same patient from one time to another.
Therefore, the practitioner should understand that the
patient may demonstrate all the clinical manifestations
presented or just a few of them.For example, many of the
clinical manifestations associated with a respiratory
disorder may never appear in some patients (e.g., digital
clubbing, cor pulmonale, increased hemoglobin level). As a
general rule, however, the prototypical patient usually
demonstrates many, if not most, of the manifestations
presented during the advanced stages of the disease.
• For a variety of practical reasons, some of the clinical
manifestations presented in each chapter may not actually
be measured (or measurable) in the clinical setting (e.g.,
age, mental status, severity of the disorder). They are
nevertheless conceptually important and therefore are
presented here through extrapolation. For example, the
newborn with severe respiratory distress syndrome, who
obviously has a restrictive lung disorder as a result of the
anatomic alterations associated with the disease, cannot
actually perform the maneuvers necessary for a pulmonary
function study.
• It should be noted that the clinical manifestations presented
in each chapter are based only on the one respiratory
disorder under discussion. In the clinical setting, however,
the patient often has a combination of respiratory problems
(e.g., emphysema compromised by pneumonia) and may
have manifestations related to each of the pulmonary
disorders.
This section does not attempt to present the “absolute”
pathophysiologic bases for the development of a particular clinical
manifestation. Because of the dynamic nature of many respiratory
diseases, the precise cause of some of the manifestations presented
by the patient is not always clear. In most cases, however, the
primary pathophysiologic mechanisms responsible for the various
signs and symptoms are known and understood and are described in
this section.
Management of the Disease
Each chapter provides a general overview of the current more
common therapeutic modalities (treatment protocols) used to offset
the anatomic alterations and pathophysiologic mechanisms
activated by a particular disorder.
While several respiratory therapy modalities may be safe and
effective in treating a respiratory disorder, the respiratory therapist
must have a clear conception of the following:
1. How the therapies work to offset the anatomic alterations of
the lungs caused by the disease
2. How the correction of the anatomic alterations of the lungs
work to offset the pathophysiologic mechanisms
3. How the correction of the pathophysiologic mechanisms
works to offset the clinical manifestations demonstrated by
the patient
Without this understanding, the practitioner merely goes through
the motions of performing therapeutic tasks without any feedback
of expected or measurable outcomes. ∗
∗ The reader should understand that this book is not a respiratory
pharmacology text. Its emphasis is on the appropriate modalities to
be used rather than specific pharmacologic agents.
Case Study(ies)
The case study at the end of each respiratory disease chapter
provides the reader with a realistic example of (1) the manner in
which the patient may arrive in the hospital with the disorder under
discussion; (2) the various clinical manifestations commonly
associated with the disease; (3) the way the clinical manifestations
can be gathered, organized, and documented; (4) the way an
assessment of the patient’s respiratory status is formulated from
the clinical manifestations; and (5) the way a comprehensive
treatment plan is developed from the assessment.
In essence, the case study provides the reader with a
representative example of the way in which the respiratory therapist
would gather clinical data, make an assessment, and treat a patient
with the disorder under discussion. In addition, many of the case
studies presented in the text describe a respiratory therapist
assessing and treating the patient several times—demonstrating the
importance of serial assessment and the way therapy is often up-
regulated or down-regulated on a moment-to-moment basis in the
clinical setting.
Self-Assessment Questions
Students can assess their retention of the content via self-
assessment questions available on the Evolve website at
http://evolve.elsevier.com/DesJardins/respiratory/. Questions and
answers are provided for each chapter.
Appendices and Glossary
The appendices and the glossary can be found on the Evolve
website. The appendices that are on Evolve are as follows:
Appendix I: Symbols and Abbreviations Commonly Used in
Respiratory Physiology
Appendix II: Aerosolized Medication Therapy for COPD and
Asthma
Appendix III: Antibiotics
Appendix IV: Antifungal Agents
Appendix V: Mucolytic and Expectorant Agents
Appendix VI: Positive Inotropes and Vasopressors
Appendix VII: Diuretic Agents
Appendix VIII: The Ideal Alveolar Gas Equation
Appendix IX: Physiologic Dead Space Calculation
Appendix X: Units of Measure
Appendix XI: Poiseuille’s Law
Appendix XII: PCO2/HCO3 − /pH Nomogram
Appendix XIII: Calculated Hemodynamic Measurements
Appendix XIV: DuBois Body Surface Area Chart
Appendix XV: Cardiopulmonary Profile
References
References, selected topic articles, state of the art articles, and key
references from UpToDate are provided on the Evolve website. The
student is encouraged to review the references from uptodate.com.
Approach
In writing this textbook, we have tried to present a realistic balance
between the often-esoteric language of pathophysiology and the
simple, straight-to-the-point approach generally preferred by busy
students.
Terry Des Jardins, MEd, RRT
George G. Burton, MD
∗ The reader should understand that this book is not a respiratory
pharmacology text. Its emphasis is on the appropriate modalities to
be used rather than specific pharmacologic agents.
