1. Copyright © 2006 by Mosby, Inc. Slide 1 Section III The Therapist-Driven Protocol Program— The Essentials

2. Copyright © 2006 by Mosby, Inc. Slide 2 Chapter 9 The Therapist-Driven Protocol Program and the Role of the Respiratory Care Practitioner The Therapist-Driven Protocol Program and the Role of the Respiratory Care Practitioner

3. Copyright © 2006 by Mosby, Inc. Slide 3 Therapist-Driven Protocols (TDPs) Are an Integral Part of Respiratory Care Health Services

4. Copyright © 2006 by Mosby, Inc. Slide 4 The Purpose of TDPs  Deliver individualized diagnostic and therapeutic respiratory to patients  Assist the physician with evaluating patients’ respiratory care needs and to optimize the allocation of respiratory care services

5. Copyright © 2006 by Mosby, Inc. Slide 5 The Purpose of TDPs  Determine the indications for respiratory therapy and the appropriate modalities for providing quality, cost-effective care that improves patient outcomes and decreases length of stay  Empower respiratory care practitioners to allocate care using sign- and symptom-based algorithms for respiratory treatment

6. Copyright © 2006 by Mosby, Inc. Slide 6 Respiratory TDPs Give practitioner authority to:  Gather clinical information related to the patient’s respiratory status  Make an assessment of the clinical data collected  Start, increase, decrease, or discontinue certain respiratory therapies on a moment- to-moment basis

7. Copyright © 2006 by Mosby, Inc. Slide 7 The Innate Beauty of Respiratory TDPs Is That: 1. The physician is always in the “information loop” regarding patient care 2. Therapy can be quickly modified in response to the specific and immediate needs of the patient

8. Copyright © 2006 by Mosby, Inc. Slide 8 Clinical Research Verifies These Facts Respiratory TDPs 1. Significantly improve respiratory therapy outcomes, and 2. Appreciably lower therapy costs

9. Copyright © 2006 by Mosby, Inc. Slide 9 Figure 9-1. The promise of a good TDP program.

10. Copyright © 2006 by Mosby, Inc. Slide 10 Figure 9-2. No Assessment Program in Place.

11. Copyright © 2006 by Mosby, Inc. Slide 11 The Knowledge Base Required for a Successful TDP Program The essential knowledge base includes the:  Anatomic alterations of the lungs  Pathophysiologic mechanisms activated  Clinical manifestations that develop  Treatment modalities used to correct the problem

12. Copyright © 2006 by Mosby, Inc. Slide 12 Figure 9-3. Foundations for a strong TDP program. Overview of the essential knowledge base for assessment of respiratory diseases.

13. Copyright © 2006 by Mosby, Inc. Slide 13 The Assessment Process Skills Required for a Successful TDP Program The practitioner must:  Systematically gather clinical information  Formulate an assessment  Select an optimal treatment  Document in a clear and precise manner

14. Copyright © 2006 by Mosby, Inc. Slide 14 Figure 9-4. The way knowledge, assessment, and a TDP program interface.

15. Copyright © 2006 by Mosby, Inc. Slide 15 Common Respiratory Assessments— Excerpts (see Table 9-1) Clinical DataAssessment WheezingBronchospasm RhonchiSecretions in large airways Weak coughPoor ability to mobilize secretions ABGsAcute ventilatory failure pH7.24 pH7.24 Pa CO 2 73 Pa CO 2 73 HCO 3 - 27 HCO 3 - 27 Pa O 2 53 Pa O 2 53

16. Copyright © 2006 by Mosby, Inc. Slide 16 Severity Assessment

17. Copyright © 2006 by Mosby, Inc. Slide 17 Table 9-2. Respiratory Care Protocol Severity Assessment— Excerpts Item0 point1 point2 points3 points4 pointsTotal Points Breath soundsClearBilateralBilateralBilateralAbsent and/or______ cracklescrackleswheezing,diminish & rhonchicrackles &bilateral and/or rhonchisevere wheezing, crackles, or rhonchi CoughStrong,ExcessiveExcessiveThickThick______ spontaneous,bronchialbronchialbronchialbronchial nonproductivesecretions &secretions butsecretions &secretions but strong coughweak coughweak coughno cough

18. Copyright © 2006 by Mosby, Inc. Slide 18 Severity Assessment Case Example SEVERITY ASSESSMENT CASE EXAMPLE 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 YEARS BEFORE THIS ADMISSION (3 POINTS). THE PATIENT HAD NO RECENT SURGERY HISTORY, AND HE WAS AMBULATORY, ALERT, AND COOPERATIVE (0 POINTS). HE COMPLAINED OF DYSPNEA AND WAS USING HIS ACCESSORY MUSCLES OF INSPIRATION (3 POINTS). AUSCULTATION REVEALED BILATERAL RHONCHI OVER BOTH LUNG FIELDS (3 POINTS). HIS COUGH WAS WEAK AND PRODUCTIVE OF THICK GRAY SECRETIONS (3 POINTS). A CHEST RADIOGRAPH REVEALED PNEUMONIA (CONSOLIDATION) IN THE LEFT LOWER LUNG LOBE (3 POINTS). ON ROOM AIR HIS ARTERIAL BLOOD GAS VALUES WERE pH 7.52, Pa CO 2 54, HCO 3 - 41, AND Pa O 2 52—ACUTE ALVEOLAR HYPERVENTILATION ON CHRONIC VENTILATORY FAILURE (3 POINTS). USING THE SEVERITY ASSESSMENT FORM SHOWN IN TABLE 9-2, THE FOLLOWING TREATMENT SELECTION AND ADMINISTRATION FREQUENCY WOULD BE APPROPRIATE: TOTAL SCORE: 17 TREATMENT SELECTION: CHEST PHYSICAL THERAPY FREQUENCY OF ADMINISTRATION: FOUR TIMES A DAY; AS NEEDED

19. Copyright © 2006 by Mosby, Inc. Slide 19 The Top Four Respiratory Protocols  Oxygen therapy protocol  Bronchopulmonary hygiene therapy protocol  Hyperinflation therapy protocol  Aerosolized medication therapy protocol

20. Copyright © 2006 by Mosby, Inc. Slide 20 Common Respiratory Assessments and Treatment Plans—Excerpts (see Table 9-1) Clinical DataAssessmentTx Plan WheezingBronchospasmbeta 2 agent Rhonchi &Secretions in large airways Weak coughPoor ability to mobilize secretionsCPT ABGsAcute ventilatory failureMechanical ventilation pH7.24 pH7.24 Pa CO 2 73 Pa CO 2 73 HCO 3 - 27 HCO 3 - 27 Pa O 2 53 Pa O 2 53

21. Copyright © 2006 by Mosby, Inc. Slide 21 Oxygen Therapy Protocol 9-1

22. Copyright © 2006 by Mosby, Inc. Slide 22

23. Copyright © 2006 by Mosby, Inc. Slide 23

24. Copyright © 2006 by Mosby, Inc. Slide 24 Oxygen Therapy Protocol 9-1— Close-ups

25. Copyright © 2006 by Mosby, Inc. Slide 25

26. Copyright © 2006 by Mosby, Inc. Slide 26

27. Copyright © 2006 by Mosby, Inc. Slide 27

28. Copyright © 2006 by Mosby, Inc. Slide 28

29. Copyright © 2006 by Mosby, Inc. Slide 29 Common Oxygen Therapy Selections  Nasal cannula  Oxygen mask  Venturi mask  Partial rebreathing mask  Nonrebreathing mask

30. Copyright © 2006 by Mosby, Inc. Slide 30 Bronchopulmonary Hygiene Therapy Protocol 9-2

31. Copyright © 2006 by Mosby, Inc. Slide 31

32. Copyright © 2006 by Mosby, Inc. Slide 32

33. Copyright © 2006 by Mosby, Inc. Slide 33 Bronchopulmonary Hygiene Therapy Protocol 9-2— Close-ups

34. Copyright © 2006 by Mosby, Inc. Slide 34

35. Copyright © 2006 by Mosby, Inc. Slide 35

36. Copyright © 2006 by Mosby, Inc. Slide 36

37. Copyright © 2006 by Mosby, Inc. Slide 37 Common Bronchopulmonary Hygiene Therapy Selections  Increased fluid intake  Cough and deep breathe  Chest physical therapy  Suctioning  Bronchoscopy assist  Mucolytic aerosol

38. Copyright © 2006 by Mosby, Inc. Slide 38 Hyperinflation Therapy Protocol 9-3 (Lung Expansion Protocol)

39. Copyright © 2006 by Mosby, Inc. Slide 39

40. Copyright © 2006 by Mosby, Inc. Slide 40

41. Copyright © 2006 by Mosby, Inc. Slide 41 Hyperinflation Therapy Protocol 9-3 (Lung Expansion Protocol)— Close-ups

42. Copyright © 2006 by Mosby, Inc. Slide 42

43. Copyright © 2006 by Mosby, Inc. Slide 43

44. Copyright © 2006 by Mosby, Inc. Slide 44

45. Copyright © 2006 by Mosby, Inc. Slide 45

46. Copyright © 2006 by Mosby, Inc. Slide 46 Common Hyperinflation Therapy Selections  Cough and deep breathe  Incentive spirometry  IPPB  CPAP  PEEP  PEEP

47. Copyright © 2006 by Mosby, Inc. Slide 47 Aerosolized Medication Therapy Protocol 9-4

48. Copyright © 2006 by Mosby, Inc. Slide 48

49. Copyright © 2006 by Mosby, Inc. Slide 49

50. Copyright © 2006 by Mosby, Inc. Slide 50 Aerosolized Medication Therapy Protocol 9-4— Close-ups

51. Copyright © 2006 by Mosby, Inc. Slide 51

52. Copyright © 2006 by Mosby, Inc. Slide 52

53. Copyright © 2006 by Mosby, Inc. Slide 53

54. Copyright © 2006 by Mosby, Inc. Slide 54 Common Aerosolized Medication Selections  Bronchodilator agents  Sympathomimetics  Parasympatholytics  Mucolytic agents  Antiinflammatory agents  Antibiotic agents

55. Copyright © 2006 by Mosby, Inc. Slide 55 Mechanical Ventilation Protocol 9-5

56. Copyright © 2006 by Mosby, Inc. Slide 56

57. Copyright © 2006 by Mosby, Inc. Slide 57

58. Copyright © 2006 by Mosby, Inc. Slide 58 Mechanical Ventilation Protocol 9-5— Close-ups

59. Copyright © 2006 by Mosby, Inc. Slide 59

60. Copyright © 2006 by Mosby, Inc. Slide 60

61. Copyright © 2006 by Mosby, Inc. Slide 61

62. Copyright © 2006 by Mosby, Inc. Slide 62

63. Copyright © 2006 by Mosby, Inc. Slide 63 Disorder: Normal Lung Mechanics but Patient Has Apnea  Disease characteristics  Normal compliance and airway resistance  Ventilator mode  Volume ventilation in the AC or SIMV mode  Or pressure ventilation—either PRVC or PC  Tidal volume and respiratory rate  10 to 12 ml/kg  6 to 10 bpm to 10 bpm when SIMV mode is used to 10 bpm when SIMV mode is used Table 9-3. Common Ventilatory Management Strategies

64. Copyright © 2006 by Mosby, Inc. Slide 64 Normal Lung Mechanics, cont.  Flow rate  60 to 80 L/min  I:E ratio  1:2  FI O 2  Low to moderate  General goals and/or concerns  Care to ensure plateau pressure of 30 cm H 2 O or less  Smaller tidal volumes (<7 ml/kg) should be avoided because atelectasis can develop Table 9-3. Common Ventilatory Management Strategies, cont.

65. Copyright © 2006 by Mosby, Inc. Slide 65 Disorder: Chronic Obstructive Pulmonary Disease (COPD)  Disease characteristics  High lung compliance and high airway resistance  Ventilator mode  Volume ventilation in the AC or SIMV mode  Or pressure ventilation—either PRVC or PC  Noninvasive positive pressure ventilation (NPPV) is good alternative  Tidal volume and respiratory rate  Good starting point: 10 ml/kg and 10 to12 bpm  A small tidal volume (8-10 ml/kg) and 8 to 10 bpm with increased flow rates to allow adequate expiratory time Table 9-3. Common Ventilatory Management Strategies, cont.

66. Copyright © 2006 by Mosby, Inc. Slide 66 COPD, cont.  Flow rate  60 L/min  I:E ratio  1:2 or 1:3  FI O 2  Low to moderate  General goals and/or concerns  Air-trapping and auto-PEEP can occur when expiratory time is too short  ↑ Expiratory time to offset auto-PEEP  May ↑ inspiratory flow up to 100 L/min to ↑ expiratory time  May ↓ VT or rate to ↑ expiratory time  Do not overventilate COPD patients with chronically high Pa CO 2 levels Table 9-3. Common Ventilatory Management Strategies, cont.

67. Copyright © 2006 by Mosby, Inc. Slide 67 Disorder: Acute Asthmatic Episode  Disease characteristics  High airway resistance  Ventilator mode  SIMV mode is recommended to offset air-trapping  Tidal volume and respiratory rate  Good starting point: 8 to 10 ml/kg  Rate of 10 to 12 bpm  When air-trapping is extensive, a lower tidal volume (5-6 ml/kg) and slower rate may be required Table 9-3. Common Ventilatory Management Strategies, cont.

68. Copyright © 2006 by Mosby, Inc. Slide 68 Acute Asthmatic Episode, cont.  Flow rate  60 L/min  I:E ratio  1:2 or 1:3  FI O 2  Start at 100% and titrate downward per Sp O 2 and ABGs  General goals and/or concerns  In severe cases, the development of auto-PEEP may be inevitable  With controlled ventilation, a small amount of PEEP to offset auto-PEEP may be cautiously applied Table 9-3. Common Ventilatory Management Strategies, cont.

69. Copyright © 2006 by Mosby, Inc. Slide 69 Disorder: Acute Respiratory Distress Syndrome  Disease characteristics  Diffuse, uneven alveolar injury  Ventilator mode  Volume ventilation in the AC or SIMV mode  Or pressure ventilation—PRVC or PC  Tidal volume and respiratory rate  Typically, started at low tidal volumes and higher rates 8 mL/kg and adjusted downward to 6 ml/kg; or 4 ml/kg 8 mL/kg and adjusted downward to 6 ml/kg; or 4 ml/kg Respiratory rate as high as 35 bpm Respiratory rate as high as 35 bpm Table 9-3. Common Ventilatory Management Strategies, cont.

70. Copyright © 2006 by Mosby, Inc. Slide 70 Acute Respiratory Distress Syndrome, cont.  Flow rate  60 to 80 L/min  I:E ratio  1:1 or 1:2  Do what is necessary to meet a rapid respiratory rate  FI O 2  Less than 0.6 if possible  General goals and/or concerns  Goal is to limit transpulmonary pressures  30 cm H 2 O or less if possible  PEEP is usually needed to prevent atelectasis  Permissive hypercapnia may be allowed Table 9-3. Common Ventilatory Management Strategies, cont.

71. Copyright © 2006 by Mosby, Inc. Slide 71 Disorder: Postoperative Ventilatory Support  Disease characteristics  Often normal compliance and airway resistance  Ventilator mode  SIMV with pressure support  Or AC volume ventilation  Or pressure ventilation—either PRVC for PC  Tidal volume and respiratory rate  Good starting point: 10 to 12 ml/kg  Rate of 10 to 12 bpm However, larger tidal volumes (12-15 ml/kg) and slower rates (6-10 bpm) may be used to maintain lung volume However, larger tidal volumes (12-15 ml/kg) and slower rates (6-10 bpm) may be used to maintain lung volume Table 9-3. Common Ventilatory Management Strategies, cont.

72. Copyright © 2006 by Mosby, Inc. Slide 72 Postoperative Ventilatory Support, cont.  Flow rate  60 L/min  I:E ratio  1:2  FI O 2  Low to moderate  General goals and/or concerns  PEEP or CPAP of 3 to 5 cm H 2 O may be applied to offset atelectasis Table 9-3. Common Ventilatory Management Strategies, cont.

73. Copyright © 2006 by Mosby, Inc. Slide 73 Disorder: Neuromuscular Disorder  Disease characteristics  Normal compliance and airway resistance  Ventilator mode  Volume ventilation in the AC or SIMV mode  Or pressure ventilation—either PRVC or PC  Tidal volume and respiratory rate  Good starting point: 12 to 15 ml/kg  Rate of 10 to 12 bpm Table 9-3. Common Ventilatory Management Strategies, cont.

74. Copyright © 2006 by Mosby, Inc. Slide 74 Neuromuscular Disorder, cont.  Flow rate  60 L/min  I:E ratio  1:2  FI O 2  Low to moderate  General goals and/or concerns  PEEP of 3 to 5 cm H 2 O may be applied to offset atelectasis Table 9-3. Common Ventilatory Management Strategies, cont.

75. Copyright © 2006 by Mosby, Inc. Slide 75 Overview Summary of a Good TDP Program

76. Copyright © 2006 by Mosby, Inc. Slide 76 Figure 9-5. Overview of the essential components of a good TDP program.

77. Copyright © 2006 by Mosby, Inc. Slide 77 Figure 9-5. Close-up.

78. Copyright © 2006 by Mosby, Inc. Slide 78 Figure 9-5. Close-up.

79. Copyright © 2006 by Mosby, Inc. Slide 79 Figure 9-5. Overview of the essential components of a good TDP program.

80. Copyright © 2006 by Mosby, Inc. Slide 80 Figure 9-6 Respiratory Care Protocol Program Assessment Form— Excerpts

81. Copyright © 2006 by Mosby, Inc. Slide 81 Oxygen Therapy Clinical Indicators  History  Sp O 2 <80%  Pa O 2 <60 mm Hg  Acute hypoxemia  ↑ Respiratory rate  ↑ Pulse  Cyanosis  Confusion Figure 9-6. Respiratory care protocol program assessment form—Example Excerpts

82. Copyright © 2006 by Mosby, Inc. Slide 82 Respiratory Assessment Examples  Mild hypoxemia  Moderate hypoxemia  Severe hypoxemia  Severity score: __________ Figure 9-6. Respiratory care protocol program assessment form—Example excerpts.

83. Copyright © 2006 by Mosby, Inc. Slide 83 Treatment Plan Oxygen Therapy Examples:  Nasal cannula  Oxygen mask  28% Venturi mask Frequency: _______________ Figure 9-6. Respiratory care protocol program assessment form—Example excerpts.

84. Copyright © 2006 by Mosby, Inc. Slide 84 Common Anatomic Alterations of the Lungs  Atelectasis  Alveolar consolidation  ↑ Alveolar-capillary membrane thickness  Bronchospasm  Excessive bronchial secretions  Distal airway and alveolar weakening

85. Copyright © 2006 by Mosby, Inc. Slide 85 Box 9-2. Pathophysiologic Mechanisms Commonly Activated in Respiratory Disorders  Decreased V/Q ratio  Alveolar diffusion block  Decreased lung compliance  Stimulation of oxygen receptors  Deflation reflex  Irritant reflex  Pulmonary reflex  Increased airway resistance  Air-trapping and alveolar hyperinflation (See clinical scenarios.)

86. Copyright © 2006 by Mosby, Inc. Slide 86 Clinical Scenarios Activated by the Common Anatomic Alterations of the Lungs

87. Copyright © 2006 by Mosby, Inc. Slide 87 Atelectasis Clinical Scenario

88. Copyright © 2006 by Mosby, Inc. Slide 88 Figure 9-7. Atelectasis clinical scenario.

89. Copyright © 2006 by Mosby, Inc. Slide 89 Figure 9-7. Atelectasis—close-ups.

90. Copyright © 2006 by Mosby, Inc. Slide 90 Figure 9-7. Atelectasis clinical scenario—close-ups.

91. Copyright © 2006 by Mosby, Inc. Slide 91 Figure 9-7. Atelectasis clinical scenario—close-ups.

92. Copyright © 2006 by Mosby, Inc. Slide 92 Figure 9-7. Atelectasis clinical scenario—close-ups.

93. Copyright © 2006 by Mosby, Inc. Slide 93 Figure 9-7. Atelectasis clinical scenario—close-ups.

94. Copyright © 2006 by Mosby, Inc. Slide 94 Figure 9-7. Atelectasis clinical scenario.

95. Copyright © 2006 by Mosby, Inc. Slide 95 Alveolar Consolidation Clinical Scenario

96. Copyright © 2006 by Mosby, Inc. Slide 96 Figure 9-8. Alveolar consolidation clinical scenario.

97. Copyright © 2006 by Mosby, Inc. Slide 97 Figure 9-8. Alveolar consolidation clinical scenario (e.g., pneumonia)—close-ups.

98. Copyright © 2006 by Mosby, Inc. Slide 98 Figure 9-8. Alveolar consolidation clinical scenario—close-ups.

99. Copyright © 2006 by Mosby, Inc. Slide 99 Figure 9-8. Alveolar consolidation clinical scenario—close-ups.

100. Copyright © 2006 by Mosby, Inc. Slide 100 Figure 9-8. Alveolar consolidation clinical scenario—close-ups.

101. Copyright © 2006 by Mosby, Inc. Slide 101 Figure 9-8. Alveolar consolidation clinical scenario—close-ups.

102. Copyright © 2006 by Mosby, Inc. Slide 102 Figure 9-8. Alveolar consolidation clinical scenario.

103. Copyright © 2006 by Mosby, Inc. Slide 103 Increased Alveolar-Capillary Membrane Thickness Clinical Scenario

104. Copyright © 2006 by Mosby, Inc. Slide 104 Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario.

105. Copyright © 2006 by Mosby, Inc. Slide 105 Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario (e.g., ARDS)—close-ups.

106. Copyright © 2006 by Mosby, Inc. Slide 106 Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario—close-ups.

107. Copyright © 2006 by Mosby, Inc. Slide 107 Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario—close-ups.

108. Copyright © 2006 by Mosby, Inc. Slide 108 Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario—close-ups.

109. Copyright © 2006 by Mosby, Inc. Slide 109 Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario—close-ups.

110. Copyright © 2006 by Mosby, Inc. Slide 110 Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario.

111. Copyright © 2006 by Mosby, Inc. Slide 111 Bronchospasm Clinical Scenario

112. Copyright © 2006 by Mosby, Inc. Slide 112 Figure 9-10. Bronchospasm clinical scenario (e.g., asthma).

113. Copyright © 2006 by Mosby, Inc. Slide 113 Figure 9-10. Bronchospasm clinical scenario (e.g., asthma)—close-ups.

114. Copyright © 2006 by Mosby, Inc. Slide 114 Figure 9-10. Bronchospasm clinical scenario (e.g., asthma)—close-ups.

115. Copyright © 2006 by Mosby, Inc. Slide 115 Figure 9-10. Bronchospasm clinical scenario (e.g., asthma)—close-ups.

116. Copyright © 2006 by Mosby, Inc. Slide 116 Figure 9-10. Bronchospasm clinical scenario (e.g., asthma)—close-ups.

117. Copyright © 2006 by Mosby, Inc. Slide 117 Figure 9-10. Bronchospasm clinical scenario (e.g., asthma)—close-ups.

118. Copyright © 2006 by Mosby, Inc. Slide 118 Figure 9-10. Bronchospasm clinical scenario (e.g., asthma).

119. Copyright © 2006 by Mosby, Inc. Slide 119 Excessive Bronchial Secretions Clinical Scenario

120. Copyright © 2006 by Mosby, Inc. Slide 120 Figure 9-11. Excessive bronchial secretions clinical scenario.

121. Copyright © 2006 by Mosby, Inc. Slide 121 Figure 9-11. Excessive bronchial secretions clinical scenario—close-ups.

122. Copyright © 2006 by Mosby, Inc. Slide 122 Figure 9-11. Excessive bronchial secretions clinical scenario—close-ups.

123. Copyright © 2006 by Mosby, Inc. Slide 123 Figure 9-11. Excessive bronchial secretions clinical scenario—close-ups.

124. Copyright © 2006 by Mosby, Inc. Slide 124 Figure 9-11. Excessive bronchial secretions clinical scenario—close-ups.

125. Copyright © 2006 by Mosby, Inc. Slide 125 Figure 9-11. Excessive bronchial secretions clinical scenario—close-ups.

126. Copyright © 2006 by Mosby, Inc. Slide 126 Figure 9-11. Excessive bronchial secretions clinical scenario.

127. Copyright © 2006 by Mosby, Inc. Slide 127 Distal Airway and Alveolar Weakening Clinical Scenario

128. Copyright © 2006 by Mosby, Inc. Slide 128 Fig. 9-12 Distal airway and alveolar weakening clinical scenario.

129. Copyright © 2006 by Mosby, Inc. Slide 129 Figure 9-12. Distal airway and alveolar weakening clinical scenario—close-ups.

130. Copyright © 2006 by Mosby, Inc. Slide 130 Figure 9-12. Distal airway and alveolar weakening clinical scenario—close-ups.

131. Copyright © 2006 by Mosby, Inc. Slide 131 Figure 9-12. Distal airway and alveolar weakening clinical scenario—close-ups.

132. Copyright © 2006 by Mosby, Inc. Slide 132 Figure 9-12. Distal airway and alveolar weakening clinical scenario—close-ups.

133. Copyright © 2006 by Mosby, Inc. Slide 133 Figure 9-12. Distal airway and alveolar weakening clinical scenario—close-ups.

134. Copyright © 2006 by Mosby, Inc. Slide 134 Figure 9-12. Distal airway and alveolar weakening clinical scenario.

135. Copyright © 2006 by Mosby, Inc. Slide 135 Figure 9-13. A three-component model of a prototype airway. A, Airway lumen; B, airway wall; C, supporting structure.