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1

Kreit, John W. Respiratory Mechanics. Edited by John W. Kreit. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780190670085.003.0001.

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Ventilation can occur only when the respiratory system expands above and then returns to its resting or equilibrium volume. This is just another way of saying that ventilation depends on our ability to breathe. Although breathing requires very little effort and even less thought, it’s nevertheless a fairly complex process. Respiratory Mechanics reviews the interaction between applied and opposing forces during spontaneous and mechanical ventilation. It discusses elastic recoil, viscous forces, compliance, resistance, and the equation of motion and the time constant of the respiratory system. I
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2

Muders, Thomas, and Christian Putensen. Pressure-controlled mechanical ventilation. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0096.

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Beside reduction in tidal volume limiting peak airway pressure minimizes the risk for ventilator-associated-lung-injury in patients with acute respiratory distress syndrome. Pressure-controlled, time-cycled ventilation (PCV) enables the physician to keep airway pressures under strict limits by presetting inspiratory and expiratory pressures, and cycle times. PCV results in a square-waved airway pressure and a decelerating inspiratory gas flow holding the alveoli inflated for the preset time. Preset pressures and cycle times, and respiratory system mechanics affect alveolar and intrinsic positi
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3

Martin-Loeches, Ignacio, and Antonio Artigas. Respiratory support with positive end-expiratory pressure. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0094.

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Positive-end-expiratory pressure (PEEP) is the pressure present in the airway (alveolar pressure) above atmospheric pressure that exists at the end of expiration. The term PEEP is defined in two particular settings. Extrinsic PEEP (applied by ventilator) and intrinsic PEEP (PEEP caused by non-complete exhalation causing progressive air trapping). Applied (extrinsic) PEEP—is usually one of the first ventilator settings chosen when mechanical ventilation (MV) is initiated. Applying PEEP increases alveolar pressure and volume. The increased lung volume increases the surface area by reopening and
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4

MacIntyre, Neil R. Indications for mechanical ventilation. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0091.

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Mechanical ventilation is indicated when the patient’s ability to ventilate the lung and/or effect gas transport across the alveolar capillary interface is compromised to point that harm is imminent. In practice, this means addressing one or more of three fundamental pathophysiological processes—loss of proper ventilatory control, ventilatory muscle demand-capability imbalances, and/or loss of alveolar patency. A fourth general indication involves providing a positive pressure assistance to allow tolerance of an artificial airway in the patient unable to maintain a patent and protected airway.
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Ware, Lorraine B. Pathophysiology of acute respiratory distress syndrome. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0108.

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The acute respiratory distress syndrome (ARDS) is a syndrome of acute respiratory failure characterized by the acute onset of non-cardiogenic pulmonary oedema due to increased lung endothelial and alveolar epithelial permeability. Common predisposing clinical conditions include sepsis, pneumonia, severe traumatic injury, and aspiration of gastric contents. Environmental factors, such as alcohol abuse and cigarette smoke exposure may increase the risk of developing ARDS in those at risk. Pathologically, ARDS is characterized by diffuse alveolar damage with neutrophilic alveolitis, haemorrhage,
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6

Lucangelo, Umberto, and Massimo Ferluga. Pulmonary mechanical dysfunction in the critically ill. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0084.

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In intensive care units practitioners are confronted every day with mechanically-ventilated patients and should be able to sort out from all the data available from modern ventilators to tailored patient ventilatory strategy. Real-time visualization of pressure, flow and tidal volume provide valuable information on the respiratory system, to optimize ventilatory support and avoiding complications associated with mechanical ventilation. Early determination of patient–ventilator asynchrony, air-trapping, and variation in respiratory parameters is important during mechanical ventilation. A correc
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7

Joynt, Gavin M., and Gordon Y. S. Choi. Blood gas analysis in the critically ill. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0072.

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Arterial blood gases allow the assessment of patient oxygenation, ventilation, and acid-base status. Blood gas machines directly measure pH, and the partial pressures of carbon dioxide (PaCO2) and oxygen (PaO2) dissolved in arterial blood. Oxygenation is assessed by measuring PaO2 and arterial blood oxygen saturation (SaO2) in the context of the inspired oxygen and haemoglobin concentration, and the oxyhaemoglobin dissociation curve. Causes of arterial hypoxaemia may often be elucidated by determining the alveolar–arterial oxygen gradient. Ventilation is assessed by measuring the PaCO2 in the
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8

Hedenstierna, Göran, and Hans Ulrich Rothen. Physiology of positive-pressure ventilation. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0088.

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During positive pressure ventilation the lung volume is reduced because of loss of respiratory muscle tone. This promotes airway closure that occurs in dependent lung regions. Gas absorption behind the closed airway results sooner or later in atelectasis depending on the inspired oxygen concentration. The elevated airway and alveolar pressures squeeze blood flow down the lung so that a ventilation/perfusion mismatch ensues with more ventilation going to the upper lung regions and more perfusion going to the lower, dependent lung. Positive pressure ventilation may impede the return of venous bl
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9

Cuartero, Mireia, and Niall D. Ferguson. High-frequency ventilation and oscillation. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0098.

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High-frequency oscillatory ventilation (HFOV) is a key member of the family of modes called high-frequency ventilation and achieves adequate alveolar ventilation despite using very low tidal volumes, often below the dead space volume, at frequencies significantly above normal physiological values. It has been proposed as a potential protective ventilatory strategy, delivering minimal alveolar tidal stretch, while also providing continuous lung recruitment. HFOV has been successfully used in neonatal and paediatric intensive care units over the last 25 years. Since the late 1990s adults with ac
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10

Lumb, Andrew B., and Natalie Drury. Respiratory physiology in anaesthetic practice. Edited by Jonathan G. Hardman. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780199642045.003.0002.

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Moving away from the structure of traditional texts, this chapter follows the journey of oxygen molecules as they move from inspired air to their point of use in mitochondria, with some digressions along the way to cover other relevant aspects of respiratory physiology. The chapter encompasses all the key aspects of respiratory physiology and also highlights physiological alterations that occur under both general and regional anaesthesia, moving the physiological principles discussed into daily anaesthetic practice. The chapter explores relevant anatomy of the airways, lungs, and pleura. The h
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11

Pevernagie, Dirk. Positive airway pressure therapy. Edited by Sudhansu Chokroverty, Luigi Ferini-Strambi, and Christopher Kennard. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780199682003.003.0017.

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This chapter describes positive airway pressure (PAP) therapy for sleep disordered breathing. Continuous PAP (CPAP) acts as a mechanical splint on the upper airway and is the treatment of choice for moderate to severe obstructive sleep apnea (OSA). Autotitrating CPAP may be used when the pressure demand for stabilizing the upper airway is quite variable. In other cases, fixed CPAP is sufficient. There is robust evidence that CPAP reduces the symptomatic burden and risk of cardiovascular comorbidity in patients with moderate to severe OSA. Bilevel PAP is indicated for treatment of respiratory d
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12

Trzcinka, Agnieszka. Aspiration Pneumonitis. Edited by Matthew D. McEvoy and Cory M. Furse. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780190226459.003.0016.

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Aspiration pneumonitis during the perioperative period is a serious complication and involves passage of sterile gastric contents into the airway resulting in alveolar damage. The mechanism of aspiration pneumonitis is characterized by a significant inflammatory reaction. The risk of aspiration is highest during anesthesia induction, but it is also present during emergence and extubation. The risk factors include delayed gastric emptying (gastritis, pain, pregnancy, obesity, elevated intracranial pressure), emergency surgery, upper abdominal surgery, and difficulty securing the airway. Anesthe
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13

Kreit, John W. Cardiovascular–Pulmonary Interactions. Edited by John W. Kreit. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780190670085.003.0003.

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Intramural pressures within a tube or circuit determine the rate and direction of flow, whereas the transmural pressure of an elastic structure determines its volume. In Chapter 1, we applied these principles when talking about the pressure needed to overcome viscous forces and elastic recoil during ventilation. In this chapter, we use them to explain changes in blood flow between two portions of the circulatory system and changes in the volume and size of the heart chambers. Cardio–Pulmonary Interactions provides an overview of essential cardiovascular physiology as well as an in-depth discus
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14

Gattinoni, Luciano, and Alfredo Lissoni. Pathophysiology and therapeutic strategy of respiratory acidosis. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0113.

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Out of 15–30 × 10–3 moles/day of protons derived from the hydration of CO2 only 40–60 × 10–9 moles/day remain unbounded in the plasma. If the CO2 production exceeds the excretion, the CO2 content in plasma and tissue rises (respiratory acidosis) until a new equilibrium is reached. In fact, doubling the PCO2 may compensate the halving of alveolar ventilation with unchanged excretion of the CO2 metabolically produced. Body reacts to respiratory acidosis increasing the secretion of chloride associated with ammonium. The process leads to an increase of bicarbonate in the plasma with an associated
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15

Li Bassi, Gianluigi, and J. D. Marti. Chest physiotherapy and tracheobronchial suction in the ICU. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0121.

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The airway lining fluid is a biphasic layer covering the respiratory tract epithelium. It has antimicrobial and immunomodulatory properties, and it is formed by a gel-phase (mucus), and a low-viscosity inner layer (sol-phase) that provides lubrication for ciliary beating. Mucus is continuously cleared from the airways through the ciliated epithelium and via the two-phase gas–liquid flow mechanism (i.e. coughing). Mucus production in healthy subjects is approximately 10–100 mL/day. Whereas, mucociliary clearance rates range between 4 and 20 mm/min. Critically-ill, mechanically-ventilated patien
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16

Gattinon, Luciano, and Eleonora Carlesso. Acute respiratory failure and acute respiratory distress syndrome. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199687039.003.0064.

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Respiratory failure (RF) is defined as the acute or chronic impairment of respiratory system function to maintain normal oxygen and CO2 values when breathing room air. ‘Oxygenation failure’ occurs when O2 partial pressure (PaO2) value is lower than the normal predicted values for age and altitude and may be due to ventilation/perfusion mismatch or low oxygen concentration in the inspired air. In contrast, ‘ventilatory failure’ primarily involves CO2 elimination, with arterial CO2 partial pressure (PaCO2) higher than 45 mmHg. The most common causes are exacerbation of chronic obstructive pulmon
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17

Gattinon, Luciano, and Eleonora Carlesso. Acute respiratory failure and acute respiratory distress syndrome. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780199687039.003.0064_update_001.

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Respiratory failure (RF) is defined as the acute or chronic impairment of respiratory system function to maintain normal oxygen and CO2 values when breathing room air. ‘Oxygenation failure’ occurs when O2 partial pressure (PaO2) value is lower than the normal predicted values for age and altitude and may be due to ventilation/perfusion mismatch or low oxygen concentration in the inspired air. In contrast, ‘ventilatory failure’ primarily involves CO2 elimination, with arterial CO2 partial pressure (PaCO2) higher than 45 mmHg. The most common causes are exacerbation of chronic obstructive pulmon
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18

Coppola, Silvia, and Franco Valenza. Inhalation injury in the ICU. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0107.

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Inhalation injury represents one of the most serious associated injuries complicating the care of thermally-injured patient. It can result in severe respiratory failure and acute respiratory distress syndrome (ARDS) by three mechanisms—thermal or chemical injury, and impairment of systemic oxygen supply. Thermal injury can cause erythema, ulceration, and progressive, life-threatening oedema, particularly of the upper airways. Chemical injury is due to irritants or cytotoxic compounds, and depends on the material burned, the temperature of the fire, and the amount of oxygen present in the fire
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19

Frew, Anthony. Air pollution. Edited by Patrick Davey and David Sprigings. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780199568741.003.0341.

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Any public debate about air pollution starts with the premise that air pollution cannot be good for you, so we should have less of it. However, it is much more difficult to determine how much is dangerous, and even more difficult to decide how much we are willing to pay for improvements in measured air pollution. Recent UK estimates suggest that fine particulate pollution causes about 6500 deaths per year, although it is not clear how many years of life are lost as a result. Some deaths may just be brought forward by a few days or weeks, while others may be truly premature. Globally, household
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20

Garner, Justin, and David Treacher. Intensive care unit and ventilation. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780199657742.003.0009.

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Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are characterized by rapidly developing hypoxaemic respiratory failure and bilateral pulmonary infiltrates on chest X-ray. ALI/ARDS are a relatively frequent diagnosis in protracted-stay patients in the intensive care unit. The pathology is a non-specific response to a wide variety of insults. Impaired gas exchange, ventilation-perfusion mismatch, and reduced compliance ensue. Mechanical ventilation is the mainstay of management, along with treatment of the underlying cause. Mortality remains very high at around 40%. The co
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