Uploaded bykapitsebou
13 views

Test Bank for Perinatal and Pediatric Respiratory Care, 3rd Edition: Walsh

Test Bank for Perinatal and Pediatric Respiratory Care, 3rd Edition: Walsh Test Bank for Perinatal and Pediatric Respiratory Care, 3rd Edition: Walsh Test Bank for Perinatal and Pediatric Respiratory Care, 3rd Edition: Walsh

Education◦
Related topics:
Educational Test Banks•
Download to read offline
Test Bank for Perinatal and Pediatric Respiratory Care, 3rd Edition: Walsh download pdf https://testbankmall.com/product/test-bank-for-perinatal-and-pediatric- respiratory-care-3rd-edition-walsh/ Visit testbankmall.com today to download the complete set of test banks or solution manuals!
We have selected some products that you may be interested in Click the link to download now or visit testbankmall.com for more options!. Test Bank for Comprehensive Perinatal and Pediatric Respiratory Care 4th Edition by Whitaker https://testbankmall.com/product/test-bank-for-comprehensive- perinatal-and-pediatric-respiratory-care-4th-edition-by-whitaker/ Test Bank for Neonatal and Pediatric Respiratory Care 5th Edition by Walsh https://testbankmall.com/product/test-bank-for-neonatal-and-pediatric- respiratory-care-5th-edition-by-walsh/ Test Bank for Neonatal and Pediatric Respiratory Care 4th Edition Brian K Walsh Download https://testbankmall.com/product/test-bank-for-neonatal-and-pediatric- respiratory-care-4th-edition-brian-k-walsh-download/ Solution Manual for A Second Course in Statistics: Regression Analysis, 8th Edition, William Mendenhall, Terry T. Sincich https://testbankmall.com/product/solution-manual-for-a-second-course- in-statistics-regression-analysis-8th-edition-william-mendenhall- terry-t-sincich/
International Management Culture, Strategy, and Behavior Luthans 9th Edition Test Bank https://testbankmall.com/product/international-management-culture- strategy-and-behavior-luthans-9th-edition-test-bank/ Test Bank for Critical Thinking 12th Edition https://testbankmall.com/product/test-bank-for-critical-thinking-12th- edition/ Test Bank for Health Psychology Biopsychosocial Interactions 8th Edition Edward P Sarafino Download https://testbankmall.com/product/test-bank-for-health-psychology- biopsychosocial-interactions-8th-edition-edward-p-sarafino-download/ Test Bank for Essentials of Dental Radiography, 9th Edition : Thomson https://testbankmall.com/product/test-bank-for-essentials-of-dental- radiography-9th-edition-thomson/ Solution Manual for Selling Today, 12/E 12th Edition : 013325092X https://testbankmall.com/product/solution-manual-for-selling- today-12-e-12th-edition-013325092x/
Test Bank for Managerial Accounting for Managers, 5th Edition, Eric Noreen, Peter Brewer, Ray Garrison https://testbankmall.com/product/test-bank-for-managerial-accounting- for-managers-5th-edition-eric-noreen-peter-brewer-ray-garrison/
Description: With the in-depth coverage you need, this text helps you provide quality treatment for neonates, infants and pediatric patients. It discusses the principles of neonatal and pediatric respiratory care while emphasizing clinical application. Not only is this edition updated with the latest advances in perinatal and pediatric medicine, but it adds a new chapter on pediatric thoracic trauma plus new user-friendly features to simplify learning. 1. Front Matter 2. Dedication 3. Contributors 4. Reviewers 5. Preface 6. AUDIENCE 7. New to this Edition 8. LEARNING AIDS 9. Evolve Resources—http://evolve.elsevier.com/Walsh/perinatal/ 10. For the Instructor 11. For Students 12. ACKNOWLEDGMENTS 13. Section I Fetal Development, Assessment, and Delivery 14. Chapter 1 Fetal Lung Development 15. LEARNING OBJECTIVES 16. STAGES OF LUNG DEVELOPMENT 17. Embryonal Stage 18. TABLE 1-1 Classification of Stages of Human Intrauterine Lung Growth 19. Pseudoglandular Stage 20. FIGURE 1-1 Embryonal stage of lung development: the trachea and major bronchi at A to C, 4 weeks; D and E, 5 weeks; F, 6 weeks; G, 8 weeks. 21. Canalicular Stage 22. FIGURE 1-2 Canalicular stage of lung development at 22 weeks of gestation. A terminal bronchiole (bottom left) leads into a prospective acinus. Note that branches are sparse. 23. Saccular Stage 24. Alveolar Stage 25. POSTNATAL LUNG GROWTH 26. FIGURE 1-3 Saccular stage of lung development at 29 weeks of gestation. Secondary crests (arrows) begin to divide saccules into smaller compartments.
27. FIGURE 1-4 Alveolar stage of lung development at 36 weeks of gestation. Note the double capillary network (solid arrows, center and right) and the single capillary layer (arrow at left). 28. FIGURE 1-5 Alveolar stage of lung development at 36 weeks of gestation: thin-walled alveoli are present. 29. FACTORS AFFECTING PRENATAL AND POSTNATAL LUNG GROWTH 30. ABNORMAL LUNG DEVELOPMENT 31. PULMONARY HYPOPLASIA 32. ALVEOLAR CELL DEVELOPMENT AND SURFACTANT PRODUCTION 33. FETAL LUNG LIQUID 34. ASSESSMENT QUESTIONS 35. References 36. Chapter 2 Fetal Gas Exchange and Circulation 37. LEARNING OBJECTIVES 38. MATERNAL-FETAL GAS EXCHANGE 39. FIGURE 2-1 Implanted human embryo, approximately day 28, showing the relationship of the chorion, amnion, and chorionic villi. The umbilical cord and tail are difficult to differentiate in this view. 40. Box 2-1 Origin of the Various Tissue Systems From the Three Embryonic Germ Layers* 41. ECTODERM 42. MESODERM 43. ENDODERM 44. CARDIOVASCULAR DEVELOPMENT 45. Early Development 46. TABLE 2-1 Timetable of Significant Events During Fetal Heart Development 47. Chamber Development 48. FIGURE 2-2 Formation of the primordial heart chambers after fusion of the heart tubes at a gestational age of 3 weeks. 49. FIGURE 2-3 A, Sagittal view of the developing heart during week 4, showing the position of the atrium, bulbus cordis, ventricles, and endocardial cushions merging from the ventral and dorsal sides. B, Traditional view of the developing heart during weeks 4 to 5, showing budding interventricular septum, fused endocardial cushions. septum primum, and the left and right atria. The ventricular septum continues to fold and grow upward between the ventricles. 50. Maturation 51. FIGURE 2-4 Frontal view of the fetal heart between weeks 5 and 6, showing the development of the four chambers nearing completion. The arrow shows the one- way path through the foramen ovale. 52. FIGURE 2-5 Frontal view (right) and side view (left) schematics of the foramen ovale. The septum primum forms the flap, and the septum secundum remains open to form the foramen ovale. The arrows show the one-way path through the foramen ovale. 53. FETAL CIRCULATION AND FETAL SHUNTS
54. FIGURE 2-6 A diagram of the fetal circulation, showing blood containing oxygen and nourishment moving from the placenta to the fetal heart and through the three fetal shunts: the ductus venosus, the foramen ovale, and the ductus arteriosus. 55. TRANSITION TO EXTRAUTERINE LIFE 56. ASSESSMENT QUESTIONS 57. References 58. Chapter 3 Antenatal Assessment and High-risk Delivery 59. LEARNING OBJECTIVES 60. MATERNAL HISTORY AND RISK FACTORS 61. Preterm Birth 62. Cervical Insufficiency 63. Toxic Habits in Pregnancy 64. Alcohol 65. Smoking 66. Cocaine 67. Hypertension and Diabetes Mellitus 68. Hypertension 69. Diabetes 70. Pregestational Diabetes 71. Gestational Diabetes Mellitus 72. Infectious Diseases 73. Group B Streptococcus 74. Herpes Simplex Virus 75. Hepatitis B Virus and Human Immunodeficiency Virus 76. HIV 77. HBV 78. Fetal Membranes, Umbilical Cord, and Placenta 79. Disorders of Amniotic Fluid Volume 80. Mode of Delivery 81. Breech Presentation 82. Assisted Vaginal Delivery 83. Cesarean Delivery 84. ANTENATAL ASSESSMENT 85. Ultrasound 86. FIGURE 3-1 Ultrasound picture of a fetus at 23 weeks of gestation (top), with a Doppler study of the fetal heart (bottom). Dop, Doppler; Fr, frame; Freq, frequency; PRF, pulse-repetition frequency; SV, sample volume; WF, wall filter. 87. Amniocentesis 88. Nonstress Test and Contraction Stress Test 89. FIGURE 3-2 A nonstress test recording, produced with a cardiotocograph. A, The fetal heart rate (FHR) is recorded with an ultrasound probe as changes in beats per minute (bpm) over time. B, Uterine contractions (UC) are recorded with a pressure transducer as changes in pressure (mm Hg) over time. In this case the nonstress test is reactive, indicating normal uteroplacental function. 90. Fetal Biophysical Profile 91. INTRAPARTUM MONITORING
92. HIGH-RISK CONDITIONS 93. Preterm Labor 94. TABLE 3-1 Biophysical Profile Scoring 95. FIGURE 3-3 Early decelerations (coinciding with uterine contraction) are usually due to fetal head compression and pose little threat to the fetus. 96. FIGURE 3-4 Variable decelerations are the most common. They are due to cord compression and have different configurations. Repetitive severe variable decelerations are associated with increased risk of fetal hypoxia. 97. FIGURE 3-5 Late decelerations are due to uteroplacental insufficiency. They usually begin at the peak of the contraction and are associated with fetal distress. 98. TABLE 3-2 Normal Values for Fetal Scalp Blood and Umbilical Cord Blood Gases 99. Postterm Pregnancy 100. ASSESSMENT QUESTIONS 101. References 102. Chapter 4 Neonatal Assessment and Resuscitation 103. LEARNING OBJECTIVES 104. PREPARATION 105. Box 4-1 Perinatal Factors Associated With Increased Risk of Neonatal Depression 106. ANTEPARTUM (FETOMATERNAL) 107. INTRAPARTUM 108. STABILIZING THE NEONATE 109. Drying and Warming 110. FIGURE 4-1 Correct and incorrect head positions for resuscitation. 111. Clearing the Airway 112. FIGURE 4-2 Meconium aspirator, with an endotracheal tube attached to one end and a suction source attached at the other end. 113. Providing Stimulation 114. ASSESSING THE NEONATE 115. Respiration 116. Heart Rate 117. Skin Color 118. Apgar Score 119. FIGURE 4-3 Algorithm for resuscitation of the newborn. HR, Heart rate (beats/min). 120. TABLE 4-1 Apgar Scoring 121. Apgar Score in the Very Low Birth Weight Infant 122. RESUSCITATING THE NEONATE 123. Oxygen Administration 124. Ventilation 125. FIGURE 4-4 Correct technique for holding a mask to the face of a newborn. Note that fingers do not touch the neck or soft tissue under the chin. 126. FIGURE 4-5 Incorrect technique for holding a mask to the face of a newborn. Note that the fingers are touching the neck and soft tissue under the chin, causing airway obstruction.
127. TABLE 4-2 Advantages and Disadvantages of Three Devices for Delivering Positive-pressure Ventilation to Neonates 128. Chest Compressions 129. Medications 130. Epinephrine 131. Volume Expanders 132. Naloxone 133. Sodium Bicarbonate 134. Postresuscitation Care 135. Ethical Considerations 136. Assessment Questions 137. References 138. Section II Assessment and Monitoring of the Neonatal and Pediatric Patient 139. Chapter 5 Examination and Assessment of the Neonatal Patient 140. LEARNING OBJECTIVES 141. GESTATIONAL AGE AND SIZE ASSESSMENT 142. FIGURE 5-1 Ballard examination for estimating gestational age, using scores determined on the basis of neurologic and physical signs. 143. PHYSICAL EXAMINATION 144. FIGURE 5-2 Overview of conditions producing neonatal morbidity and mortality by birth weight and gestational age. RDS, Respiratory distress syndrome. 145. Vital Signs 146. TABLE 5-1 Normal Values for Vital Signs in the Neonatal Patient 147. General Inspection 148. FIGURE 5-3 “Waiter's tip” positioning of the left arm of an infant with brachial plexus injury from a traumatic delivery. 149. Respiratory Function 150. TABLE 5-2 Common Dermal Findings in the Neonatal Patient 151. FIGURE 5-4 Silverman scoring system for assessing the magnitude of respiratory distress. Exp., Expiratory; insp., inspiratory; retract., retraction. 152. Chest and Cardiovascular System 153. TABLE 5-3 Signs of Respiratory Distress in the Neonatal Patient 154. Abdomen 155. FIGURE 5-5 Infant with prune-belly syndrome. 156. Head and Neck 157. Musculoskeletal System, Spine, and Extremities 158. FIGURE 5-6 Infant with an open spinal defect. 159. FIGURE 5-7 Infant with myelomeningocele. 160. Cry 161. NEUROLOGIC ASSESSMENT 162. LABORATORY ASSESSMENT 163. TABLE 5-4 Laboratory Values in the Neonatal Patient 164. Box 5-1 “Red Flags” in Neonatal Patients 165. RESPIRATORY 166. CARDIAC 167. RENAL
168. GASTROINTESTINAL 169. METABOLIC 170. GENERAL 171. ASSESSMENT QUESTIONS 172. References 173. Chapter 6 Examination and Assessment of the Pediatric Patient 174. LEARNING OBJECTIVES 175. PATIENT HISTORY 176. Chief Complaint 177. New Patient History 178. Box 6-1 New Patient History 179. CHIEF COMPLAINT OR PRIMARY REASON FOR VISIT 180. History of Present Illness 181. Past Medical History 182. Review of Symptoms 183. Family History 184. Social and Environmental Histories 185. Follow-up or Established Patient History 186. Box 6-2 Follow-up or Established Patient History 187. CHIEF COMPLAINT AND/OR PREVIOUS DIAGNOSIS OR PROBLEM 188. Interim History 189. Review of Key Components 190. PULMONARY EXAMINATION 191. Box 6-3 Pulmonary Examination 192. Inspection 193. TABLE 6-1 Normal Respiratory Rates in Sleeping and Awake Pediatric Patients 194. FIGURE 6-1 Head bobbing. 195. Palpation 196. FIGURE 6-2 Intercostal retractions. Soft tissue between the ribs is pulled inward (retracted) because of the extremely high negative pleural pressure. 197. FIGURE 6-3 Suprasternal retractions. Soft tissue in the suprasternal space is retracted because of high negative pressure, most often caused by the patient's attempt to breathe against an airway obstruction. 198. Percussion 199. FIGURE 6-4 Subcostal/substernal retractions. Airway obstruction results in a pulling inward of the lower costal margins. The abdomen is protruding (1), and there is a sunken substernal notch (2). See-saw movement of the chest and stomach is also present. 200. FIGURE 6-5 Technique for determining tracheal position in the older child. 201. Auscultation 202. NONPULMONARY EXAMINATION 203. Box 6-4 Nonpulmonary Examination: Findings Possibly Associated With Pulmonary Disease 204. GENERAL 205. EARS, EYES, NOSE, THROAT
206. HEART 207. ABDOMEN 208. SKIN 209. EXTREMITIES 210. FIGURE 6-6 A, Normal finger viewed from above and in profile, and the changes occurring in established clubbing, viewed from above and in profile. B, The finger on the left demonstrates normal profile (ABC) and normal hyponychial (ABD) nail-fold angles of 169 and 183 degrees, respectively. The clubbed finger on the right shows increased profile and hyponychial nail-fold angles of 191 and 203 degrees, respectively. C, Distal phalangeal finger depth (DPD)/interphalangeal finger depth (IPD) represents the phalangeal depth ratio. In normal fingers, the IPD is greater than the DPD. In clubbing, this relationship is reversed. D, Schamroth sign: in the absence of clubbing, opposition of the index fingers nail-to-nail creates a diamond-shaped window (arrowhead). In clubbed fingers, the loss of the profile angle due to an increase in tissue at the nail bed causes obliteration of this space (arrowhead). 211. LABORATORY TESTING 212. Box 6-5 Laboratory Evaluation 213. THE HEALTH CARE TEAM 214. CASE STUDIES 215. CASE 1 216. Family History 217. CASE 2 218. CASE 3 219. Box 6-6 History Taking in the Pediatric Patient With Asthma 220. MANIFESTATIONS 221. AGGRAVATING FACTORS 222. ALLEVIATING FACTORS 223. ASSOCIATED CONDITIONS (REVIEW OF SYMPTOMS) 224. FAMILY HISTORY 225. ENVIRONMENTAL EXPOSURES 226. ASSESSMENT QUESTIONS 227. References 228. Chapter 7 Pulmonary Function Testing and Bedside Pulmonary Mechanics 229. LEARNING OBJECTIVES 230. DEFINITIONS 231. SPECIAL CONSIDERATIONS 232. Neonatal Testing 233. Pediatric Testing 234. Instrumentation 235. Selection of Data for Analysis 236. MECHANICS OF BREATHING IN NEWBORNS 237. FIGURE 7-1 A pneumotachometer with a pulmonary function testing (PFT) computer system. As gas flow passes through the restrictive element, the difference in pressure between P1 and P2 is converted to a flow measurement. The flow rate over time is then converted to volume measurement. 238. Lung Inflation and Transpulmonary Pressure
239. NEONATAL PULMONARY FUNCTION TESTING IN THE LABORATORY 240. Measuring Static Compliance and Airway Resistance 241. Measuring Functional Residual Capacity 242. FIGURE 7-2 Volume–pressure loops of tidal breathing at various levels of functional residual capacity (FRC): a, low FRC; b, normal FRC; c, elevated FRC. 243. Helium Dilution Method 244. Nitrogen Washout Method 245. Plethysmography 246. Measuring Maximal Expiratory Flow by Rapid Thoracic Compression Technique 247. FIGURE 7-3 Partial expiratory flow–volume (PEFV) curves with identification of maximal expiratory flow at FRC (VmaxFRC), demonstrating a normal resting tidal breath and one with flow limitation. A, Normal; B, abnormal (flow limited). 248. PEDIATRIC PULMONARY FUNCTION TESTING IN THE LABORATORY 249. Standard Spirometry 250. Flow–Volume Loop 251. FIGURE 7-4 A normal standard time–volume spirometry graph, depicting the forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), and forced expiratory flow between 25% and 75% of vital capacity (FEF25-75). 252. FIGURE 7-5 Normal flow–volume loop, showing both the expiratory and the inspiratory loops. The usual flow rates are identified. Note that no forced expiratory volume in 1 second (FEV1) is evident because there is no time axis. FEF50, Forced expiratory flow at 50% of vital capacity; FVC, forced vital capacity; PEFR, peak expiratory flow rate; RV, residual volume; TLC, total lung capacity. 253. FIGURE 7-6 This expiratory flow–volume loop demonstrates the patient's failure to exhale completely to residual volume (RV). This will artificially decrease FVC and increase FEF50. 254. FIGURE 7-7 Comparison of a forced expiratory flow–volume curve starting from 100% of total lung capacity (TLC) with a curve starting at 75% of TLC. The computer software will have no way of knowing that the smaller curve was not started at 100% TLC and will start the smaller curve at zero volume. This artificially decreases FVC, PEFR, and FEF50. A, Both curves start at TLC, as displayed by the computer. B, The curves, if matched at RV, would reflect that the smaller curve was not started at full lung volume. Clinicians must do their best to ensure that the patient starts the expiratory maneuver at 100% TLC. 255. Forced Vital Capacity, Forced Expiratory Volume, and Ratio of Forced Expiratory Volume to Forced Vital Capacity 256. Forced Expiratory Flow at 25% to 75% and at 50% of Vital Capacity 257. TABLE 7-1 Pulmonary Function Measurements in Children 258. Spirometric Values 259. FIGURE 7-8 Prebronchodilator and postbronchodilator expiratory loops produced by a 5-year-old patient with asthma. The prebronchodilator curve is slightly concave with respect to the volume axis, which is not evident on the postbronchodilator curve. The FEF50 is the only prebronchodilator measurement below the expected normal range of variability; it increased by 70% after bronchodilator therapy. FEF50, Forced expiratory flow at 50% of vital capacity; FEV1,
forced expiratory volume in 1 second; FVC, forced vital capacity; PEFR, peak expiratory flow rate. 260. TABLE 7-2 Characterization of Obstructive and Restrictive Patterns in Pulmonary Function Testing 261. Lung Volumes 262. FIGURE 7-9 Body plethysmography “box.” 263. FIGURE 7-10 Graphic display of the subdivisions of total lung capacity (TLC), from quiet tidal breathing on the left to maximal inhalation and exhalation on the right. ERV, Expiratory reserve volume; FRC, functional residual capacity; IC, inspiratory capacity; RV, residual volume; VC, vital capacity; VT, tidal volume. 264. Provocation Tests 265. TABLE 7-3 Positive Methacholine Challenge in a 7-year-old Girl With Chronic Cough* 266. MEASURING PULMONARY MECHANICS AT THE BEDSIDE 267. Calculated Parameters 268. Tidal Volume 269. Respiratory Frequency 270. Minute Ventilation 271. Rapid Shallow Breathing Index 272. Inspiratory and Expiratory Times 273. Lung Compliance 274. Airway Resistance 275. Time Constants 276. FIGURE 7-11 Tracing of pressure, flow, and volume over time (in seconds). Exp, Expiration; Insp, inspiration. 277. Pressure, Flow, and Volume Over Time 278. Flow–Volume Loops 279. FIGURE 7-12 Patterns of flow–volume loops. A, Normal; B, restrictive; C, obstructive. 280. FIGURE 7-13 Flow–volume loops showing various forms of airway obstruction. A, Fixed obstruction; B, variable extrathoracic obstruction; C, variable intrathoracic obstruction. 281. Pressure–Volume Loops 282. FIGURE 7-14 Pressure–volume loops demonstrating normal and decreased lung compliance. A, Normal lung compliance; B, decreased lung compliance. 283. Lung Overdistention 284. FIGURE 7-15 Pressure–volume loops demonstrating overdistention. Note the “penguin” or “bird's beak” appearance in the shape of the loops. These loops demonstrate idealized slopes (dashed lines) for change in compliance for the entire breath (C) and change in compliance in the last 20% of inspiratory pressure (C20). The C20/C ratio identifies lung overdistention. 285. Work of Breathing 286. Other Bedside Tests 287. Vital Capacity 288. Peak Expiratory Flow Rate 289. Maximal Inspiratory Pressure
290. Complex Bedside Measurements 291. SUMMARY 292. ASSESSMENT QUESTIONS 293. References 294. Chapter 8 Radiographic Assessment 295. LEARNING OBJECTIVES 296. RADIOGRAPHIC TECHNIQUE 297. FIGURE 8-1 Expiratory frontal chest radiograph shows normal decrease in left lung volume. Tooth (arrow) obstructs the right mainstem bronchus and causes air trapping in the right lung. 298. NORMAL CHEST ANATOMY 299. FIGURE 8-2 A, Left lower lobe pneumonia abuts the diaphragm, leading to nonvisualization of the normal edge of the diaphragm. The cardiac border is demarcated because the lingula (a segment of the upper lobe of the left lung) is normally aerated. B, Only the right hemidiaphragm is visualized because the left is obscured by the left lower lobe pneumonia. Major fissure appears as an edge (arrow). 300. FIGURE 8-3 Normal frontal view of the chest demonstrating the thoracic inlet (1), carina (the point at which the trachea splits into the two mainstem bronchi) (2), the aortic arch (3), and pulmonary hila (4). 301. FIGURE 8-4 Normal thymus abuts the minor fissure (arrow) and has a curved lateral margin. 302. FIGURE 8-5 A, Infant with respiratory distress syndrome on lower ventilator setting. B, Same infant on higher ventilator setting. 303. POSITIONING OF LINES AND TUBES 304. AIRWAY OBSTRUCTION 305. FIGURE 8-6 Enlarged tonsils (arrow) appear to hang down into the hypopharynx. The nasopharynx (arrowhead) is narrowed from enlarged adenoids located posterior and superior. 306. FIGURE 8-7 “Steepling” of the subglottic airway is caused by croup. 307. FIGURE 8-8 Enlarged epiglottis (arrow) appears as a “thumb” projecting into the airway. 308. FIGURE 8-9 Hypopharynx and trachea are displaced away from the cervical spine by a retropharyngeal abscess. 309. FIGURE 8-10 Edema from a coin in the upper esophagus causes marked narrowing of the adjacent trachea. The child presented with stridor and difficulty with swallowing. 310. RESPIRATORY DISTRESS IN THE NEWBORN 311. FIGURE 8-11 Even after intubation, the lungs are hypoinflated and have a granular pattern with faint air bronchograms in this infant with respiratory distress syndrome. 312. Box 8-1 Respiratory Distress in the Newborn 313. FIGURE 8-12 Large left pneumothorax appears black and outlines the partially collapsed left lung and left cardiac border (arrow). 314. FIGURE 8-13 Pneumomediastinum elevates the left lobe of the thymus to produce a “spinnaker sail” in this child, who also has a large left pneumothorax.
315. FIGURE 8-14 Massive pulmonary interstitial emphysema throughout the left lung causes shift of the mediastinum to the right and downward displacement of the left hemidiaphragm. 316. FIGURE 8-15 Meconium aspiration appears as a coarse asymmetric pattern. Enlargement of the heart may be secondary to fluid overload in this infant. 317. FIGURE 8-16 Group B streptococcal pneumonia presents in this infant with hyperinflation, small right pleural effusion (arrow), and hazy infiltrative pattern. 318. FIGURE 8-17 Multiple “cysts” in the left hemithorax are air-filled loops of bowel that herniated through a defect in the left hemidiaphragm. The abdomen is scaphoid from decreased bowel content. 319. ATELECTASIS 320. FIGURE 8-18 Left upper lobe collapse causes elevation of the left hemidiaphragm and crowding of the left ribs from volume loss. The cardiac and superior mediastinal borders are indistinct because of the “silhouette sign” while the diaphragm remains demarcated by the aerated left lower lobe. 321. FIGURE 8-19 Collapsed right middle lobe appears as a triangular wedge of increased density extending anteriorly and inferiorly toward the anterior chest wall and diaphragm. 322. PNEUMONIA 323. FIGURE 8-20 Round pneumonia (arrow) in the left lower lobe simulates a mass. 324. ASTHMA 325. CYSTIC FIBROSIS 326. FIGURE 8-21 Coarse interstitial markings, hyperinflation, bronchiectasis, mucous plugging (arrow), atelectasis (arrowhead), and enlarged pulmonary hila are all demonstrated in this child with cystic fibrosis. 327. FIGURE 8-22 Pneumonia was the precipitating precursor to acute respiratory distress syndrome, with densely consolidated lungs and air bronchograms (arrow). 328. ACUTE RESPIRATORY DISTRESS SYNDROME 329. CHEST TRAUMA 330. FIGURE 8-23 Trauma to the chest resulted in extensive bilateral air leaks and densely consolidated pulmonary contusions. Multiple rib fractures are present. 331. Assessment Questions 332. References 333. Chapter 9 Pediatric Flexible Bronchoscopy 334. LEARNING OBJECTIVES 335. INDICATIONS 336. Diagnostic Bronchoscopy 337. Stridor 338. Box 9-1 Indications for Flexible Bronchoscopy 339. DIAGNOSTIC 340. Airway Anatomy Evaluation 341. Bronchoalveolar Lavage and Biopsy 342. Cytopathology 343. Microbiology 344. Foreign Body Aspiration
345. Hemoptysis 346. THERAPEUTIC 347. Wheeze 348. Cough 349. Radiographic Abnormalities 350. Foreign Body Aspiration 351. Hemoptysis 352. Inhalation Injury 353. Therapeutic Bronchoscopy 354. CONTRAINDICATIONS 355. Box 9-2 Contraindications to Flexible Bronchoscopy 356. ABSOLUTE CONTRAINDICATIONS 357. RELATIVE CONTRAINDICATIONS 358. EQUIPMENT 359. Flexible Bronchoscope 360. Insertion Tube 361. FIGURE 9-1 Three different sizes of pediatric flexible bronchoscopes. Top to bottom: 4.5-, 3.6-, and 2.2-mm outer diameter. Note that all scopes have similar working tube lengths. 362. Control Head and Eyepiece 363. Light Source Connector 364. Video Recording Equipment 365. PREPARATION 366. Equipment and Supplies 367. Box 9-3 Equipment and Supplies for Pediatric Flexible Bronchoscopy 368. FIGURE 9-2 Necessary equipment for basic pediatric flexible bronchoscopy includes bronchoscope, attached suction tube, 2% lidocaine jelly, lidocaine spray, three 1-ml aliquots of 1% lidocaine solution, Luken trap, gauze pads, and three to five 10-ml aliquots of normal saline for bronchoalveolar lavage. These items are placed on a clean drape on top of a portable bronchoscopy cart. 369. Patient 370. Personnel 371. PROCEDURE 372. Conscious Sedation 373. Topical Anesthesia 374. Patient Monitoring 375. Technique 376. POSTPROCEDURAL MONITORING AND COMPLICATIONS 377. EQUIPMENT MAINTENANCE 378. FIGURE 9-3 Correct placement of flexible bronchoscope in STERIS cleaning apparatus, used for chemical sterilization of the instrument. 379. COMPARISON WITH RIGID BRONCHOSCOPY 380. Assessment Questions 381. References 382. Chapter 10 Invasive Blood Gas Analysis and Cardiovascular Monitoring 383. LEARNING OBJECTIVES
384. BLOOD GAS SAMPLING 385. Pain Control 386. FIGURE 10-1 Arterial sites that may be used for peripheral artery puncture in infants and children. 387. Box 10-1 Indications for Blood Gas Analysis 388. Arterial Sampling Sites 389. Modified Allen's Test 390. ARTERIAL PUNCTURE 391. Procedure 392. Box 10-2 Equipment for Arterial Puncture and Blood Gas Collection 393. Contraindications 394. Complications 395. CAPILLARY BLOOD GAS SAMPLES 396. Puncture Sites 397. FIGURE 10-2 Recommended puncture sites (shaded areas) in infant's heel to obtain capillary blood for analysis. 398. FIGURE 10-3 Technique for grasping the finger for a capillary puncture, with recommended site for puncture indicated (shaded area). 399. Procedure 400. Box 10-3 Equipment for Capillary Puncture and Blood Gas Collection 401. FIGURE 10-4 Technique for stabilizing the heel for a capillary puncture. 402. Contraindications 403. Complications 404. ARTERIAL CATHETERS 405. Umbilical Artery Catheterization 406. FIGURE 10-5 An indwelling arterial line and continuous infusion/flush system used to monitor blood pressure and obtain blood gas samples. Exploded view shows a three-way stop-cock system. A, Normal position with stop-cock off to sampling port allows continuous monitoring of blood pressure and flushing of the line if using a (pig tail) flush system. B, Position to draw blood or inject flush solution to the patient with stop-cock turned off to flush solution. C, Position to flush sample port with stop-cock off to patient. All ports are closed at all intermediary positions 407. Peripheral Artery Catheterization 408. Procedure for Sampling 409. Complications 410. Measurements 411. CONTINUOUS INVASIVE BLOOD GAS MONITORING 412. FIGURE 10-6 An ex vivo in-line continuous blood gas monitor designed for use in critically ill newborn infants. 413. CENTRAL VENOUS CATHETERS 414. Monitoring Sites 415. Procedure 416. Complications 417. Measurements 418. PULMONARY ARTERY CATHETERIZATION
419. FIGURE 10-7 Conventional pulmonary artery (Swan-Ganz) thermodilution catheter. 420. Procedure 421. FIGURE 10-8 Examples of pressure waveform patterns at various locations in and around the heart. A, Central venous pressure; B, right ventricular pressure; C, pulmonary artery pressure; D, pulmonary capillary wedge pressure. 422. FIGURE 10-9 Pressure waveforms as the catheter travels through the right atrium (RA), right ventricle (RV), and pulmonary artery (PA), becoming wedged (pulmonary capillary wedge pressure [PCWP]). 423. Complications 424. Measurements 425. Box 10-4 Normal Pressure Values From Pulmonary Artery Catheters 426. Cardiac Output 427. TABLE 10-1 Normal Ranges of Derived Hemodynamic Parameters 428. NONINVASIVE MEASUREMENT OF CARDIAC OUTPUT AND PERFUSION 429. PATIENT INFORMATION 430. FREQUENCY 431. TABLE 10-2 Approximate Normal Range of Arterial Blood Gas Values 432. BLOOD GAS INTERPRETATION 433. Acid–Base Balance 434. Oxygenation 435. TABLE 10-3 Laboratory Values for Acid–base Disturbances 436. Box 10-5 Causes of Metabolic Acidosis 437. Box 10-6 Causes of Metabolic Alkalosis 438. Box 10-7 Causes of Respiratory Acidosis 439. LUNG DISEASE 440. IMPAIRED LUNG MOTION 441. APNEA 442. OTHER 443. Box 10-8 Causes of Respiratory Alkalosis 444. FIGURE 10-10 Oxyhemoglobin dissociation curve, illustrating the P50 value (Po2 at 50% saturation) with the effects of right and left shifts of the curve. As the curve shifts to the right, the oxygen affinity of hemoglobin decreases, more oxygen is released at a given Po2, and the P50 value increases. When the curve shifts to the left, there is increased oxygen affinity, less oxygen is released at a given Po2, and the P50 value decreases. 445. TABLE 10-4 Factors That May Shift Oxyhemoglobin Dissociation Curve 446. FIGURE 10-11 Components of oxygen delivery. 447. ABNORMAL HEMOGLOBIN 448. ASSESSMENT QUESTIONS 449. References 450. Chapter 11 Noninvasive Monitoring in Neonatal and Pediatric Care 451. LEARNING OBJECTIVES 452. PULSE OXIMETRY 453. Principles of Operation
454. FIGURE 11-1 Proper alignment of light-emitting diodes (LEDs) opposite the photodetector in a sensor applied to a patient's finger. 455. Application 456. FIGURE 11-2 Differences in light absorption between deoxygenated hemoglobin (0% saturation) and oxygenated hemoglobin (100% saturation) during pulsatile signals. 457. FIGURE 11-3 Pulse oximeter probe attached to a child's toe. 458. Disadvantages 459. TRANSCUTANEOUS MONITORING 460. Principles of Operation 461. Application 462. FIGURE 11-4 Transcutaneous oxygen monitor electrode placed on a child's arm. 463. Disadvantages 464. New Technology 465. FIGURE 11-5 Location of mainstream airway adapter (A) and sidestream adapter (B) in patient's airway. 466. CAPNOMETRY 467. Principles of Operation 468. Interpretation of Capnogram 469. FIGURE 11-6 Normal capnogram. 470. Detection of Ventilation Problems 471. Endotracheal Tube in Esophagus 472. Rebreathing 473. Obstructed Airway 474. Paralyzed Patients 475. FIGURE 11-7 Effect of rebreathing carbon dioxide on the capnogram. Note that the inspiratory level does not return to zero. 476. FIGURE 11-8 Capnogram with sloping alveolar plateau representative of airway obstruction. 477. FIGURE 11-9 Curare cleft in the alveolar plateau. 478. FIGURE 11-10 Stair effect on the descending limb of the capnogram indicating a potential pneumothorax. 479. Pneumothorax 480. Cardiogenic Oscillations 481. IMPEDANCE PNEUMOGRAPHY 482. FIGURE 11-11 Cardiogenic oscillations in synchrony with the ECG signal. 483. Principles of Operation 484. Application 485. FIGURE 11-12 Neonatal impedance pneumography. With the infant on a flat surface, the belt is positioned in line with the nipples. After the electrodes are placed, the belt is wrapped snugly around the infant's chest. 486. Disadvantages 487. ELECTROCARDIOGRAPHY 488. CALORIMETRY 489. Principles of Operation
490. Disadvantages 491. ASSESSMENT QUESTIONS 492. References 493. Section III Therapeutic Procedures for Treatment of Neonatal and Pediatric Disorders 494. Chapter 12 Oxygen Administration 495. LEARNING OBJECTIVES 496. INDICATIONS 497. Documented or Suspected Hypoxemia 498. Evidence of Hypoxemia 499. Measurement of Oxygen Tension and Saturation 500. Clinical Signs and Symptoms 501. COMPLICATIONS 502. OXYGEN ADMINISTRATION 503. Variable-performance Oxygen Delivery Systems 504. Nasopharyngeal Catheter 505. Indications and Contraindications 506. Application 507. Hazards and Complications 508. Nasal Cannula 509. FIGURE 12-1 Infant with a neonatal nasal cannula. 510. Indications and Contraindications 511. Application 512. FIGURE 12-2 NeoHold cannula/tubing holder. The 4-cm-long strip attaches to the skin with hydrocolloid while the flap on top positions and secures the tubing in place. The clear flap allows visualization of the tubing. 513. FIGURE 12-3 Tender Grip skin fixation pad. A round base of microporous tape is applied to the infant's skin. The flap on top of the base is designed to position and secure the tubing in place. 514. Blenders and Low-flow Flowmeters 515. Inspired Oxygen Determination 516. Box 12-1 Regression Equation for Estimating Nasal Cannula Fio2 at Low Flow Rates 517. Hazards and Complications 518. Simple Oxygen Mask 519. FIGURE 12-4 Infant with a simple oxygen mask. 520. Indications and Contraindications 521. Application 522. Hazards and Complications 523. Reservoir Masks 524. FIGURE 12-5 Pediatric patient with a partial-rebreathing mask, a type of reservoir mask. 525. Partial-rebreathing Mask 526. Nonrebreathing Mask 527. Fixed-performance Oxygen Delivery Systems 528. Air-entrainment Mask
529. FIGURE 12-6 Pediatric patient with an air-entrainment mask. 530. Indications and Contraindications 531. Application 532. Hazards and Complications 533. Air-entrainment Nebulizer 534. Indications and Contraindications 535. Application 536. FIGURE 12-7 Various aerosol attachments. Left to right: Face tent, T-piece attached to an endotracheal tube, pediatric aerosol mask, infant aerosol mask, and tracheostomy mask (collar). 537. FIGURE 12-8 Blow-by method of oxygen administration used in postanesthesia recovery rooms. 538. Hazards and Complications 539. High-flow Nasal Cannula 540. Indications and Contraindications 541. Application 542. Hazards and Complications 543. Enclosures 544. Oxygen Tent 545. FIGURE 12-9 Oxygen mist tent. 546. Indications and Contraindications 547. Hazards and Complications 548. Oxygen Hood 549. Indications and Contraindications 550. Application 551. FIGURE 12-10 Infant oxygen hood with gas delivered through an oxygen blender system with heated humidification. The oxygen analyzer sensor is placed inside the hood close to the infant's head. 552. FIGURE 12-11 Tent house for oxygen administration to larger infants. 553. FIGURE 12-12 Older pediatric patient requiring low oxygen concentration after surgical repair of earlobes. Because use of a face mask or cannula would require straps or tubing placed around the patient's ears, a hood is used. 554. Hazards and Complications 555. Incubators 556. Indications and Contraindications 557. Application 558. Hazards and Complications 559. Manual Resuscitation Systems 560. Self-inflating Resuscitation System 561. FIGURE 12-13 Pediatric (top) and neonatal (bottom) self-inflating manual resuscitation bags. 562. Non–self-inflating Resuscitation System 563. FIGURE 12-14 Neonatal non–self-inflating manual resuscitation bag with in- line pressure manometer. 564. ASSESSMENT QUESTIONS 565. References
566. Chapter 13 Aerosols and Administration of Medication 567. LEARNING OBJECTIVES 568. NEONATAL AND PEDIATRIC MEDICATION DELIVERY 569. Box 13-1 Factors That Reduce Rate and Depth of Aerosol Particle Deposition in Neonatal and Pediatric Patients 570. FIGURE 13-1 Although the percentage of drug deposited in the lung varies with age (darker columns), the percentage of lung deposition corrected for body weight (lighter columns) is consistent across age groups. 571. FIGURE 13-2 Assessing nebulizer performance. F, frequency; I:E, ratio of inspiratory to expiratory time; IFR, inspiratory flow rate; VT, tidal volume. 572. AEROSOL ADMINISTRATION IN NONINTUBATED INFANTS AND CHILDREN 573. DEPOSITION IN INTUBATED INFANTS 574. FIGURE 13-3 A dose of 200 μg of albuterol was administered by jet nebulizer or metered dose inhaler (MDI) with chamber to infants with bronchopulmonary dysplasia, between 1 and 4 kg in size, and either ventilated or nonventilated. Mean (SEM) values for lung deposition are shown in A, nonventilated infants (n = 13) and B, ventilated infants (n = 10). Values are given as the percentage of the amount delivered to the infants and, for nebulizers, also as the percentage of the initial nebulizer dose. The absolute amount (μg) of salbutamol deposited in the lungs (solid columns) is given for reference. 575. AEROSOL CHARACTERISTICS 576. Deposition of Particles 577. Translocation of Aerosols 578. Drug Dose Distribution 579. AEROSOL DELIVERY 580. Pneumatic Nebulizers 581. FIGURE 13-4 Aerosol generated and inhaled during nebulization therapy. A, Continuous nebulization; B, breath-enhanced nebulization; C, breath-actuated nebulization. 582. FIGURE 13-5 Distribution of albuterol delivered via nebulizer (NEB), pressurized metered-dose inhaler (MDI), and pressurized metered-dose inhaler with holding chamber (MDI/HC). 583. Large-volume Nebulizer 584. Small-particle Aerosol Generator 585. FIGURE 13-6 Diagram of small-particle aerosol generator (SPAG), which may be used with a hood, tent, mask, or ventilator. psig, Pounds-force per square inch gauge. 586. Ultrasonic Nebulizers 587. FIGURE 13-7 Aerosol is produced in an ultrasonic nebulizer by focusing sound waves, which disrupt the surface of the fluid, creating a standing wave that produces droplets. Flow from a fan pushes the aerosol out of the chamber. 588. Vibrating Mesh Nebulizers 589. Pressurized Metered-dose Inhalers 590. FIGURE 13-8 Cross-sectional diagrams of a pressurized metered-dose inhaler. 591. Technique
592. Box 13-2 Optimal Self-administration Technique for Using Pressurized Metered-dose Inhaler 593. Accessory Devices 594. Flow-triggered Device 595. Spacers and Holding Chambers 596. FIGURE 13-9 Metered dose inhaler holding chambers are spacers with one- way valves that allow the chamber to be emptied only when the patient inhales, by preventing the exhaled gas from re-entering the chamber. 597. Box 13-3 Optimal Technique for Using Pressurized Metered-dose Inhaler With Valved Holding Chamber 598. Wheezing Infants 599. Care and Cleaning 600. Dry Powder Inhalers 601. FIGURE 13-10 As patient inhales through a dry powder inhaler, inspiratory flow deaggregates particles from the powder bed or capsule and is drawn through a screen that strips the small drug particles from the larger carrier particles, creating an aerosol dispersion. 602. FIGURE 13-11 Fine particle mass delivered from a 100-μg target dose (±SD) as a function of flow rate. pMDI, Pressurized metered-dose inhaler; BAMDI, breath- actuated MDI (Autohaler); DPI 1, Rotahaler; DPI 2, Turbuhaler; DPI 3, Diskhaler. 603. FIGURE 13-12 Peak inspiratory flows in individual inexperienced children and in groups of experienced children. 604. TABLE 13-1 Differences in Inhalation Technique Between Pressurized Metered-dose Inhaler With Holding Chamber and Dry Powder Inhaler 605. DEVICE SELECTION AND COMPLIANCE 606. TABLE 13-2 Comparison of Pressurized Metered-dose Inhaler With Holding Chamber, Dry Powder Inhaler, and Nebulizer as Aerosol Delivery Device 607. EMERGENCY BRONCHODILATOR RESUSCITATION 608. Intermittent versus Continuous Therapy 609. FIGURE 13-13 Rates of hospitalization of patients with asthma from the emergency department after treatment with albuterol (control) or with albuterol and ipratropium (ipratropium). Numbers in columns, number of children tested. In patients with moderate asthma, no difference was seen in hospitalization rate. In patients with severe asthma, the benefits of combined therapy were significant. 610. Undiluted Bronchodilator 611. MECHANICAL VENTILATION 612. Box 13-4 Variables That Affect Aerosol Delivery and Deposition During Mechanical Ventilation 613. VENTILATOR RELATED 614. DEVICE RELATED 615. Metered-dose Inhaler 616. Nebulizer 617. CIRCUIT RELATED 618. DRUG RELATED 619. PATIENT RELATED 620. Factors Affecting Aerosol Delivery
621. Ventilator–Patient Interface 622. Breath Configuration 623. FIGURE 13-14 MDI holding chambers to use in-line with mechanical ventilator circuits or in intubated patients or those with tracheostomies. 624. Airway 625. Environment 626. Response Assessment 627. FIGURE 13-15 Measurements of respiratory system resistance (Rrs) before, and 15, 30, 60 and 120 min after, salbutamol treatment via a metered dose inhaler (MDI), a jet nebulizer (Jet: Sidestream), and an ultrasonic nebulizer (US). *Posttreatment values were significantly lower than the pretreatment Rrs, P < 0.0001. 628. Nebulizer Placement 629. Inhaler Adapters 630. Aerosol Particle Size 631. Endotracheal Tube 632. Heating and Humidification 633. Density of Inhaled Gas 634. Ventilator Mode and Settings 635. Technique of Aerosol Administration in Critical Care 636. BRONCHODILATOR ADMINISTRATION 637. Inhaler versus Nebulizer 638. Care of Accessory Devices and Nebulizers 639. Box 13-5 Technique for Using Nebulizers to Treat Mechanically Ventilated Patients 640. HOME CARE AND MONITORING COMPLIANCE 641. Box 13-6 Technique for Using Pressurized Metered-dose Inhalers to Treat Mechanically Ventilated Patients 642. OTHER MEDICATIONS FOR AEROSOL DELIVERY 643. Antibiotics 644. Mucoactive Agents 645. Surfactant 646. Hyperosmolar Aerosols 647. Gene Transfer Therapy 648. Aerosols for Systemic Administration 649. Insulin 650. SUMMARY 651. ASSESSMENT QUESTIONS 652. References 653. Chapter 14 Airway Clearance Techniques and Lung Volume Expansion 654. LEARNING OBJECTIVES 655. HISTORY AND CURRENT STATUS OF AIRWAY CLEARANCE TECHNIQUES 656. CHEST PHYSICAL THERAPY TECHNIQUES 657. Postural Drainage 658. Percussion 659. Postural Drainage and Percussion
660. FIGURE 14-1 Postural drainage positions for infants. A, Apical segment of the right upper lobe and apical subsegment of the apical–posterior segment of the left upper lobe. B, Posterior segment of the right upper lobe and posterior subsegment of the apical–posterior segment of the left upper lobe. C, Anterior segments of right and left upper lobes. D, Superior segments of both lower lobes. E, Posterior basal segments of both lower lobes. Postural drainage positions for infants. F, Lateral basal segment of the right lower lobe. Lateral basal segment of the left lower lobe is drained in a similar fashion but with the right side down. G, Anterior basal segment of the right lower lobe. The segments on the left side are drained in a similar fashion but with the right side down. H, Right middle lobe. I, Left lingular segment of lower lobe. 661. FIGURE 14-2 Postural drainage positions for the child or adult. The model of the tracheobronchial tree next to or above the child illustrates the segmental bronchi being drained. The stippled area on the child's chest illustrates the area to be percussed or vibrated. A, Apical segment of right upper lobe and apical subsegment of apical–posterior segment of left upper lobe (area between the clavicle and top of the scapula). B, Posterior segment of right upper lobe and posterior subsegment of apical–posterior segment of left upper lobe (area over the upper back). Postural drainage positions for the child or adult. The model of the tracheobronchial tree next to or above the child illustrates the segmental bronchi being drained. The stippled area on the child's chest illustrates the area to be percussed or vibrated. C, Anterior segments of right and left upper lobes (area between clavicle and nipple). D, Superior segments of both lower lobes (area over middle of back at tip of scapula, beside spine). E, Posterior basal segments of both lower lobes (area over lower rib cage, beside spine). F, Lateral basal segment of right lower lobe. Segment on left is drained in a similar fashion but with the right side down (area over middle portion of rib cage). G, Anterior basal segment of left lower lobe. Segment on right is drained in a similar fashion but with the left side down (area over lower ribs, below the armpit). H, Right middle lobe (area over right nipple; below breast in developing females). I, Left lingular segment of lower lobe (area over left nipple; below breast in developing females). 662. FIGURE 14-3 Proper cupping of hand for percussion. 663. FIGURE 14-4 Percussion being performed on a child with a manual percussor. 664. Vibration of the Chest Wall 665. CHEST PHYSICAL THERAPY IN THE NEWBORN 666. CHEST PHYSICAL THERAPY IN YOUNG CHILDREN 667. Adverse Consequences 668. Cough 669. Forced Expiration Technique 670. Coughing and Forced Expiration Technique 671. Positive Expiratory Pressure Therapy 672. Autogenic Drainage 673. Positive Expiratory Pressure Therapy and Autogenic Drainage 674. High-frequency Chest Compression 675. FIGURE 14-5 Graphic illustration of the depth of successive breaths by lung volumes, using the autogenic drainage technique. COPD, Chronic obstructive
pulmonary disease; ERV, expiratory reserve volume; HUFF, huff maneuver; PRED, predicted; RV, residual volume; TV, tidal volume. 676. FIGURE 14-6 Patient wearing an inflatable vest during high-frequency chest compression therapy in the home. 677. Effectiveness of Techniques 678. COMPLICATIONS OF CHEST PHYSICAL THERAPY 679. Hypoxemia 680. Position 681. Percussion 682. Atelectasis 683. Bronchospasm 684. Increased Oxygen Consumption 685. Gastroesophageal Reflux 686. Airway Obstruction and Respiratory Arrest 687. Intracranial Complications 688. Rib Fractures and Bruising 689. Airway Trauma 690. SELECTION OF PATIENTS FOR CHEST PHYSICAL THERAPY 691. Conditions in Which Chest Physical Therapy May Not Be Beneficial 692. Conditions in Which Chest Physical Therapy May Be Beneficial 693. Acute Lobar Atelectasis 694. FIGURE 14-7 Algorithm for evaluating patients for chest physical therapy. 695. Cystic Fibrosis 696. Neuromuscular Disease or Injury 697. Lung Abscess 698. CONTRAINDICATIONS 699. LENGTH AND FREQUENCY OF THERAPY 700. THERAPY MODIFICATION 701. MONITORING DURING THERAPY 702. EVALUATION OF THERAPY 703. DOCUMENTATION OF THERAPY 704. INCENTIVE SPIROMETRY 705. Indications, Contraindications, and Complications 706. Box 14-1 Indications for Incentive Spirometry 707. Devices 708. Procedure 709. Application 710. FIGURE 14-8 Child using incentive spirometry device. 711. Assessment of Therapy 712. INTERMITTENT POSITIVE-PRESSURE BREATHING 713. Indications, Contraindications, and Complications 714. Equipment 715. Box 14-2 Complications Associated With Intermittent Positive-Pressure Breathing 716. Procedure 717. Application
718. FIGURE 14-9 Intermittent positive-pressure breathing (IPPB) therapy being administered to a child, with a respirometer attached to the exhalation valve for exhaled volume monitoring. 719. Monitoring 720. Assessment of Therapy 721. FUTURE OF AIRWAY CLEARANCE THERAPY 722. ASSESSMENT QUESTIONS 723. References 724. Chapter 15 Airway Management 725. LEARNING OBJECTIVES 726. INTUBATION 727. Indications 728. Equipment 729. Endotracheal Tubes 730. TABLE 15-1 Essential Equipment for Intubation 731. FIGURE 15-1 Endotracheal tube with distance markings. 732. TABLE 15-2 Neonatal Resuscitation Program Guidelines for Pediatric Endotracheal Tube Size 733. Cuffed and Uncuffed Tubes 734. Laryngoscope Blades and Handles 735. FIGURE 15-2 Direct laryngoscopy using a straight (Miller) blade. 736. Laryngeal Mask Airway 737. FIGURE 15-3 Direct laryngoscopy using a curved (MacIntosh) blade and demonstrating proper lifting technique. Note the upward and forward lift while the wrist is held straight. 738. FIGURE 15-4 A laryngeal mask airway (LMA). 739. Suction Equipment 740. TABLE 15-3 Suggested Laryngeal Mask Airway Size Based on Weight 741. INTUBATION PROCEDURE 742. Orotracheal Intubation 743. FIGURE 15-5 Glottic structures viewed through the laryngoscope. 744. FIGURE 15-6 Anterior–posterior chest radiograph of right main bronchus intubation of a toddler. 745. FIGURE 15-7 Anterior–posterior chest radiograph of properly positioned endotracheal tube. 746. Nasotracheal Intubation 747. FIGURE 15-8 Steps used to secure an endotracheal tube (ETT) with tape. Steps A and B, Slit two pieces of tape, making a Y on one end of each piece (as shown). Turn under the end of the tape that will be wrapped around the ETT. This will make tape removal easier. Step C, Apply benzoin to the area below the nose and across the cheeks (where tape will be placed). Attach one piece of tape to the cheek and below the nose, wrapping the bottom of the Y around the ETT. The tape should be placed under the tube (chin side) first, and then wrapped around the top of the tube. Step D, Repeat step C on the other side of the face. 748. Box 15-1 Equipment for Endotracheal Tube Stabilization
749. FIGURE 15-9 The NeoBar. A commercial adaptation of the Logan bow for stabilizing an infant endotracheal tube. 750. Blind Nasal Intubation 751. Oral versus Nasal Intubation 752. Neonatal Intubation 753. Approaches to the Difficult Airway 754. Anterior Commissure Intubation 755. FIGURE 15-10 Anatomic features of the normal larynx (A), and of the larynx in the presence of mandibular hypoplasia (B) In the presence of mandibular hypoplasia, the posterior displacement of the tongue makes the larynx appear more anteriorly situated than normal. 756. FIGURE 15-11 Laryngoscope placed laterally in the right oral commissure (A), permitting more complete visualization of the larynx than when the instrument is passed in the standard midline position (B). 757. Flexible Fiberoptic Intubation 758. Emergency Tracheotomy 759. FIGURE 15-12 Laryngoscopy and intubation. A, With laryngoscope in lateral position (A), approximately 30 degrees of anterior angulation is gained over the standard midline position (B), thus permitting more complete visualization of the larynx. B, Endotracheal tube (without 15-mm anesthetic adapter) is inserted into the barrel of the laryngoscope under direct visualization. In this example, an optical stylet is used. C, The endotracheal tube is grasped with alligator forceps and advanced slightly (small arrow) as the laryngoscope is withdrawn (large arrow). D, Anesthetic adapter (15 mm) is replaced, and ventilation is begun. 760. Epiglottitis 761. FIGURE 15-13 Lateral soft tissue neck radiograph revealing epiglottitis. 762. Laryngotracheal Stenosis 763. Artificial Airway Cuff Management 764. Patient Monitoring 765. Complications 766. EXTUBATION 767. Accidental Extubation 768. Equipment 769. Procedure 770. Explanation to Patient and Parent 771. Complications 772. Extubation Failure 773. Treatment Strategies 774. Nasal Mask Ventilation, Heliox 775. Laryngotracheal Reconstruction 776. TRACHEOTOMY 777. Tracheotomy Indications 778. Tracheotomy Tubes 779. TABLE 15-4 Age and Tracheotomy Tube Size* 780. TABLE 15-5 Dimensions of Three Commonly Used Brands of Tracheotomy Tube
781. FIGURE 15-14 Midsagittal section of a trachea with tracheotomy tube in position. This reveals two common problems: suprastomal granulation tissue (open arrow) and suprastomal collapse (solid arrow). 782. FIGURE 15-15 Diagram of a tracheostomy securing system with Velcro ties. 783. Procedure and Technique 784. FIGURE 15-16 An infant in a hyperextended position for tracheotomy. 785. Complications 786. FIGURE 15-17 Tracheotomy procedure with two stay sutures placed on either side of the tracheotomy incision. 787. Tracheotomy Tube Changes 788. FIGURE 15-18 Passy-Muir tracheostomy speaking valve enabled by redirecting exhaled air around the tracheostomy tube and through the larynx and upper airway. 789. Box 15-2 Equipment Needed for Tracheotomy Tube Changes 790. Tracheotomy Home Care 791. Decannulation 792. Box 15-3 Equipment Needed for Tracheotomy Tube Care 793. FIGURE 15-19 Repair of suprastomal collapse, using absorbable sutures placed on the collapsing suprastomal cartilage and tied to the stomal skin. 794. Decannulation Methods 795. Airway Reconstruction 796. Box 15-4 Evaluation for Decannulation 797. FIGURE 15-20 Proposed grading system for subglottic stenosis based on endotracheal tube size. ID, inner diameter; NO, no obstruction. 798. FIGURE 15-21 Laryngotracheoplasty using an anteriorly placed costal cartilage graft. 799. FIGURE 15-22 A posteriorly placed costal cartilage graft maintains excellent expansion of the cricoid and glottis. 800. FIGURE 15-23 Partial cricotracheal resection. Dissection of the stenotic trachea away from the esophagus. 801. SUCTIONING 802. Procedure 803. Nasotracheal Suction 804. Bulb Suction 805. Closed Tracheal Suction Systems 806. Assessment Questions 807. References 808. Chapter 16 Surfactant Replacement Therapy 809. LEARNING OBJECTIVES 810. THE DISCOVERY OF SURFACTANT 811. FIGURE 16-1 A, Pressure–volume relationship of air-filled versus liquid-filled lung from von Neergaard's original data (1929). B, The difference in recoil attributed to a liquid–air interface (i.e., “bubble lining”) that is eliminated by a liquid-only interface. P, Pressure; tiss, tissue; int, air–liquid interface; liq, liquid. 812. SURFACTANT PHYSIOLOGY 813. Function
814. FIGURE 16-2 A, Alveolar surface tension is a manifestation of the strong attraction between molecules that are aligned on the surface of the alveoli. B, During expiration, when the alveolar radius is smaller, attraction between the molecules is stronger and there is a greater tendency to collapse. C, When surfactant is present, it spreads over the alveolus and dilutes the molecules. D, During expiration, the surfactant is compressed and the alveolar surface tension is lowered. This stabilizes the alveoli and prevents collapse of those with smaller radii. 815. Box 16-1 Surfactant Function 816. Surfactant Metabolism and Composition 817. FIGURE 16-3 A, Type II cell from a human lung, showing characteristic lamellar inclusion bodies (open arrows) within the cell, which are the storage sites of intracellular surfactant. Microvilli (solid arrows) are projecting into the alveolus (Alv). B, Beginning exocytosis of a lamellar body into the alveolar space of a human lung. C, Secreted lamellar body and newly formed tubular myelin (appearing as a lattice) in the alveolar liquid in a fetal rat lung. Membrane continuities between outer lamellar bodies and adjacent tubular myelin provide evidence of intraalveolar tubular myelin formation. 818. FIGURE 16-4 Schematic diagram of surfactant metabolism. 1, secretion of LB; 2, conversion of LB into TM; 3, generation of monolayer from TM material; 4, formation of small aggregate material from monolayer; 5, reuptake of surfactant material. In general, solid arrows indicate accepted pathways. Probable pathways are indicated by dashed arrows. N, nucleus; ER, endoplasmic reticulum; CB, composite body; LB, lamellar body; TM, tubular myelin. 819. TABLE 16-1 Components of Pulmonary Surfactant 820. FIGURE 16-5 A cross-section of an alveolus wall is shown. In the presence of surfactant protein B (not shown), dipalmitoylphosphatidylcholine (DPPC) aligns in the air–liquid interface with the hydrophobic end toward the gas phase (air space) and hydrophilic end toward the liquid phase (liquid surface). Strong molecular interactions occur between the polar heads of the hydrophobic end. Note that the polar head has a positive charge associated with its nitrogenous base (N) and a negative charge associated with its phosphate group (P). This alignment creates electrostatic forces of repulsion, pushing water molecules apart, preventing atelectasis, and holding the airway open during exhalation. 821. Hormonal Effects on Surfactant Production 822. Fetal Lung Maturity Testing 823. TABLE 16-2 Fetal Lung Maturity Testing* 824. SURFACTANT DYSFUNCTION IN ACUTE LUNG INJURY 825. Altered Surfactant Quantity 826. Altered Surfactant Composition 827. Box 16-2 Diseases That Affect Surfactant 828. Altered Surfactant Metabolism 829. Surfactant Inactivation 830. CLINICAL APPLICATIONS AND REPLACEMENT 831. Respiratory Distress Syndrome 832. Incidence 833. Treatment
834. FIGURE 16-6 Four pathways that contribute to surfactant dysfunction during acute lung injury. FRC, functional residual capacity; SP-A, surfactant protein A. 835. TABLE 16-3 Clinical Presentation of Surfactant Deficiency RDS and ARDS 836. FIGURE 16-7 A, Chest radiograph of a premature infant with respiratory distress syndrome (RDS) demonstrating diffuse reticulogranular pattern (ground- glass appearance), air bronchograms, and low lung volume. B, Chest radiograph of the same premature infant after surfactant administration, demonstrating improved lung volumes. C, Photomicrograph of normal alveoli, demonstrating normal microscopic structure of the lung of a newborn infant. Clear areas are the air- containing expanded alveoli. The colored structures that form a honeycomb lattice are the walls that line the alveolar space. D, Microscopic structure of the lung from a premature infant who died of RDS. The normal honeycomb lattice is collapsed (atelectasis), the alveolar walls are adherent to each other, and the lung is almost airless. Those air-containing spaces (clear areas) that do remain are lined by a pink- staining layer of inflammatory protein termed the hyaline membrane. 837. Prophylaxis 838. Rescue and Multiple Treatments 839. Natural versus Synthetic Preparations 840. TABLE 16-4 Surfactant Delivery 841. Nonresponders 842. TABLE 16-5 Types of Surfactant 843. Pulmonary Hemorrhage 844. Meconium Aspiration Syndrome 845. Pneumonia and Sepsis 846. Congenital Diaphragmatic Hernia 847. Extracorporeal Membrane Oxygenation 848. Acute Respiratory Distress Syndrome 849. FIGURE 16-8 Changes in oxygenation after surfactant administration. Circles, surfactant group; diamonds, placebo group. 850. Viral Bronchiolitis 851. Asthma 852. Cystic Fibrosis 853. FUTURE DIRECTIONS 854. CASE STUDIES 855. CASE 1 856. CASE 2 857. ASSESSMENT QUESTIONS 858. References 859. Chapter 17 Mechanical Ventilators 860. LEARNING OBJECTIVES 861. VENTILATOR CLASSIFICATION 862. Input Power 863. Power Conversion and Transmission 864. Control 865. Control Circuit 866. Control Variables and Waveforms
867. FIGURE 17-1 A paradigm for understanding mechanical ventilators based on the equation of motion for the respiratory system. The model illustrates that during inspiration the ventilator can control only one variable at a time. The diagram shows common waveforms for each control variable. Pressure, volume, flow, and time are also used as phase variables that determine the characteristics of each ventilatory cycle. The diagram is drawn as a flow chart to emphasize that each breath may have a different set of control and phase variables, depending on the mode of ventilation used. 868. Pressure 869. Volume 870. Flow 871. Time 872. Dual Control of the Inspiratory Phase 873. FIGURE 17-2 Criteria for determining the control variable during a ventilator- assisted inspiration. 874. Phase Variables 875. Trigger 876. Limit 877. FIGURE 17-3 Criteria for determining the phase variables during a ventilator- assisted breath. 878. Cycle 879. Baseline 880. Modes of Ventilation 881. Conditional Variables 882. Spontaneous versus Mandatory Breaths 883. Output 884. Alarm Systems 885. Input Power Alarms 886. Control Circuit Alarms 887. Output Alarms 888. NEONATAL/INFANT CRITICAL CARE VENTILATORS 889. Bear Medical Systems Bear Cub 750vs 890. Dräger Medical Babylog 8000 plus 891. Power Conversion and Transmission 892. FIGURE 17-4 Babylog 8000 plus infant ventilator (Dräger Medical). 893. Control 894. Output 895. Waveforms 896. Monitoring 897. TABLE 17-1 Control and Phase Variables for Mandatory and Spontaneous Breaths in the Operational Modes Available With the Dräger Medical Babylog 8000 plus Infant Ventilator 898. Alarms 899. Input Power Alarms 900. Control Circuit Alarm 901. Output Alarms
902. Puritan Bennett Infant Star 500 903. Sechrist IV-200 With SAVI System 904. Power Conversion and Transmission 905. FIGURE 17-5 Sechrist IV-200 infant ventilator (Sechrist Industries). 906. Control 907. Output 908. Waveforms 909. Monitoring 910. TABLE 17-2 Control and Phase Variables for Mandatory and Spontaneous Breaths in the Operational Modes Available With the Sechrist IV-200 Ventilator With SAVI System 911. Alarms 912. Input Power Alarms 913. Control Circuit Alarms 914. Output Alarms 915. UNIVERSAL NEONATAL/INFANT/PEDIATRIC/ADULT CRITICAL CARE VENTILATORS 916. V.I.P. Bird 917. Cardinal Health AVEA 918. Power Conversion and Transmission 919. Control 920. FIGURE 17-6 AVEA ventilator (Cardinal Health). 921. Output 922. Waveforms 923. Monitoring 924. Alarms 925. Input Power Alarms 926. Control Circuit Alarms 927. Dräger Medical Evita 4 and EvitaXL 928. Power Conversion and Transmission 929. FIGURE 17-7 Evita 4 ventilator (Dräger Medical). 930. Control 931. Output 932. Waveforms 933. Monitoring 934. TABLE 17-3 Control and Phase Variables for Mandatory and Spontaneous Breaths in the Operational Modes Available on the Dräger Medical Evita 4 Ventilator 935. Alarms 936. Input Power Alarms 937. Control Circuit Alarms 938. Output Alarms 939. Puritan Bennett 840 940. FIGURE 17-8 Puritan Bennett 840 ventilator (Covidien). 941. Power Conversion and Transmission 942. Control 943. Output
944. Waveforms 945. Monitoring 946. Alarms 947. Input Power Alarms 948. TABLE 17-4 Control and Phase Variables for Mandatory and Spontaneous Breaths in the Operational Modes Available on the Puritan Bennett 840 Ventilator 949. Control Circuit Alarms 950. Output Alarms 951. Newport Wave VM200 952. Maquet Servo 300A 953. Maquet SERVO-i 954. Power Conversion and Transmission 955. FIGURE 17-9 SERVO-i ventilator (Maquet). 956. Control 957. Output 958. Waveforms 959. Monitoring 960. Alarms 961. Input Power Alarms 962. TABLE 17-5 Control and Phase Variables for Mandatory and Spontaneous Breaths in the Additional Available Modes on the Maquet SERVO-i Ventilator 963. Hamilton Medical Hamilton-G5 964. Power Conversion and Transmission 965. Control 966. FIGURE 17-10 Hamilton-G5 ventilator (Hamilton Medical). 967. Output 968. Waveforms 969. Monitoring 970. Alarms 971. Input Power Alarms 972. GE Healthcare Engström Carestation 973. Power Conversion and Transmission 974. Control 975. TABLE 17-6 Control and Phase Variables for Mandatory and Spontaneous Breaths in the Additional Available Modes on the Hamilton-G5 Ventilator 976. FIGURE 17-11 Engström Carestation ventilator (GE Healthcare). 977. Output 978. Waveforms 979. Monitoring 980. Alarms 981. Input Power Alarms 982. HOME CARE VENTILATORS 983. Puritan Bennett LP10 984. TABLE 17-7 Control and Phase Variables for Mandatory and Spontaneous Breaths in the Additional Available Modes on the Engström Carestation Ventilator 985. Puritan Bennett Companion 2801
Random documents with unrelated content Scribd suggests to you:
side, one being beyond the staircase. Her companion passed through that door to the left, and she followed him. They came upon a corridor, and stopped before the last door on the left-hand side. Her guide knocked, then opened it. There was no name to give; Rosalie had no tongue to speak, no card to show. Then the door closed again, and she found herself in the presence of the man whom she had come to seek. He was sitting by a table reading. A fire was burning in the hearth near by. A high shaded lamp stood on the ground beside him. The floor was thickly carpeted, the walls were lined with books from floor to ceiling, one other door led from the room. The Master looked up as she entered, then got up, pushing the book away. “So you have come,” he said. He came forward and held out his hand. Rosalie, trembling and uncertain, returned the hand-shake, nodding. “What! you cannot speak yet?” She shook her head, but as he was withdrawing his hand she clutched it eagerly, unconscious of anything but this one little sinking straw of hope. This time he looked at her more closely. “What is it?” he asked. She raised her other hand to her throat and mouth, then pointed to him, her eyes full on his face. “I’m not the Serpent,” he answered, and he shook his head and tried to disengage his hand. But Rosalie’s fingers tightened with a fierceness and determination altogether foreign to her. Her cheeks flushed, her eyes flashed angrily; she gave one little imperious stamp with her foot. The Master looked at her and smiled—a smile that travelled from his eyes to the corners of his mouth. “I see. You do not intend to go till I have performed an—an impossibility?” Rosalie nodded in all seriousness. “It is the gift of speech you’re wanting?”
She nodded. “It’s very dangerous; leads people into all kinds of indiscretions.” She shook her head vehemently. “You think you differ from the commonality?” But Rosalie neither shook her head nor nodded. She only looked up at him with no other expression in her eyes except dumb entreaty. “Come to the light,” said he, “and try to look less ghostly. After all, if you can’t be cured you can’t. You’re brave enough to stand that, aren’t you?” Again she nodded, still looking at him. He pushed the shade of the lamp up. “Now open your mouth,” he said. Obediently Rosalie did as she was told. “Why, you’ve got a tongue!” said he, bending his brows, and stooping down to her. “Can’t you move it?” But Rosalie could not. It was complete paralysis of the muscles evidently. “Come with me, and I’ll see what I can do.” He led her through the other door into another room. The walls of this place were lined with chests and cupboards with glass fronts, containing curious instruments. In the centre was a long table. The room was also fitted up with chairs such as dentists use, and a marble washing basin fitted with water pipes, hot and cold. Yet when the light was turned on the general effect was cheerful. Rosalie found it so, at any rate, for renewed hope was springing in her heart. She sat down upon the chair he drew for her, and watched him whilst he went to the cupboard and brought out something shaped like a very long darning needle. It was thick at one end, very fine and pointed at the other. Then from another shelf containing flasks of glass polished and cut he took a liquid shining like silver, and poured some into a tiny crucible. With these he came back to her and placed them on the table. Then he looked at her, smiling. “This will hurt you very much,” he said; “but you asked for it, so you will have to go through with it.”
Anyone but Rosalie would have noticed that the expression of his face was not particularly kind. But she noticed nothing. She leant back against the head-rest; he placed his hand upon her eyes. After that they were too heavy for her to open them. She opened her mouth instead. It was a curious kind of pain, if pain it could be called. Never in the whole of her life had she ever felt anything so soothing. She could not tell how long the sensation lasted, but it ceased very suddenly. Then although her eyes were closed she felt (this was the curious part of it) a strong light shining into her mouth, right back to the roots of that so far silent tongue. It was a light that had the power to heal and strengthen, and for a long, long time it played upon every unused nerve and delicate muscle. At last all was over; the master laid his hand upon her eyes again and opened them. “Now,” said he, “the miracle has been performed. Are you satisfied?” From long custom Rosalie nodded. “You must speak,” he answered, laughing, “if but to show your appreciation of the gift.” “Thank you,” she said, quite perfectly, with just a little break in the word that took nothing from its sweetness. “Did you find the pain very bad?” “I nev-er felt it.” “Never felt it?” he repeated. “Give me your hand.” But her pulse was even, and he frowned. “Where did you come from when you came to me?” he asked, bending his eyes down to hers with a keen, penetrating glance. “I came from the temple.” “From the prayer?” “Yes.” “Then you—” but here he stopped. “I see,” he continued, but in reality he didn’t. “Did you expect I should be hurt?” she asked. “I can hardly believe you were not.” “But I should have screamed. I made no sound.”
“That was scarcely possible. For my own part, I always think it best to guard against screams, they are so unhelpful and unnecessary.” Now Rosalie looked at him, with eyes just as keen and penetrating as his had been. “Why do you stare at me?” he asked, smiling. “To see if you are disappointed.” Here he laughed. “Be careful. Your tongue is getting rather out of bounds already.” “I think you would rather have enjoyed my being hurt.” “Well, what can you expect in a country where vivisection is disallowed? One must take what little pleasure one can get.” Here he led the way back into the outer room. When they were both through he turned the key and put it in his pocket. “I rarely go in there,” he said. “Few folks are fool enough to come to me. I have no ambition to become a doctor, and I shun the popularity that hangs upon the quack.” They were both standing by the table now, one on either side. Rosalie’s eyes were fixed dreamily on a large glass ink-stand in the centre of the table. She was beginning to feel indescribably tired. There was nothing very wonderful in this, the operation had lasted longer than she was aware. But though tired, she was feeling remarkably light-hearted, longing to get outside and give herself two or three decided pinches to become convinced she was awake, and that this great good fortune of her prayer had at last come to her. But over and above the tired feeling and the unreality came gratitude to her deliverer. The thought of this made her suddenly raise her eyes and look across at him. Certainly his face was very proud, and the shadows lurking underneath his eyes and at the corners of his mouth gave it a dark, forbidding expression. It was not altogether pleasant. “The feature I like best is his nose,” thought Rosalie. “The one that frightens me most is his mouth; the one that most interests me is his eyes.” “You have been very kind to me,” she said. “Is there any way in which I can pay you back?”
But he shook his head. “I do not think you could give me anything tangible, but perhaps you yourself will be able to suggest something.” Rosalie flushed to the roots of her hair. “I haven’t anything,” she answered. “Not even a soul?” “What is that?” “That part of you which under certain conditions becomes immortal.” “That part of me belongs to the Serpent.” “The Serpent passed you on body and soul to me.” “The Serpent did nothing of the sort,” she answered vehemently, if slowly. “I—I—I—” “You what?” “I nothing.” His eyebrows came together in a frown. “Yes,” he answered quietly, “there is one way in which you can pay me back. Speak the truth in answering my questions.” “I’ll try,” said Rosalie meekly. “Then put an ending to that ‘I—I—I—.’” “I came because I thought it was time. I got a little bit tired of the Serpent.” “Why?” “Because it never took any notice of me.” “Are you sure?” Rosalie’s curious eyes looked up innocently and met his. “Does that surprise you very much?” “I confess that it does.” “Do you know, I’m very tired. If you don’t mind, I’ll come again to- morrow and talk it over.” But he shook his head, and smiled again. “I don’t think I’ll let you go,” he said. “Your answers are not very satisfactory. Besides, where is there you can go?”
“Oh, with a tongue one can go anywhere and do anything.” “You think so?” “Yes.” And here from sheer weariness and exhaustion she slipped down in the arm-chair beside her. It had been a very hard day, and the ending had told upon her strength. She had not fainted, however, she was only sleeping. Mr. Barringcourt crossed the room and looked at her very narrowly, even dropping on one knee to examine her features more nearly. It was a very pale, thin, and tired face he looked at, delicate and fragile, with dark lashes, and faint blue shadows underneath the closed eyes. The backs of her hands were rough, and he took each up and examined it as though he had been a fortune-teller—back and front. Then he began walking slowly back and forwards through the room. His face, though handsome after a kind, was certainly not of the most prepossessing; and yet in repose his expression was one of weariness and contempt. “What shall I do with her?” he muttered. “Keep her to prevent blabbing as usual. Keep her and bring her up to talk properly. When she is old enough, or rather fit enough, I’ll let her out on a lease long enough to take her to the devil. Always the same! everlastingly the same! coming and going, with nothing to give and everything to ask. Dull to the very core, chattering like magpies, smiling and aping God knows what! Rich and poor, all of them alike. And for some reason best known to myself I stand it. What an excellent patient fisherman I should make!” Then he sat down again very deliberately in his chair, and drew the book he had been reading towards him, at the same ringing a bell. The same man who had admitted Rosalie answered it. “Take her away, and see she doesn’t get out,” said he, without looking up; and the other evidently understood so well that he never asked a question.
CHAPTER VI NEW EXPERIENCES When Rosalie awoke next morning, it was with a pardonable sense of bewilderment and estrangement. Instead of the little bedroom, bare of carpet, and devoid of all furniture, except the poorest and the simplest, she found herself in one that was really palatial. The bed had deep hangings of red silk, and she was not up to date enough to tear them down as breeding microbes and all things unhealthy. Then by degrees, her eyes travelling beyond the bed, she gradually became acquainted with the other things within the room, washstand, dressing-table, sofa, chairs; and here Rosalie gave a squeal of delight, and jumped out of bed, for there opposite was a wardrobe, as respectable as carved black oak could make it. But it was not the wardrobe that attracted her attention so much as the mirror set full length in its middle door—a mirror larger than she had ever seen before or dreamt about. Rosalie was not vain, but she had always entertained a great longing to see her feet at the same time as her head, and had thought it only a luxury and privilege accorded to the rich. When she had become accustomed to this novel vision she walked over towards the windows. Here, so far as beauty was concerned, a disappointment waited on her. All three of them looked upon a high blank wall opposite. It gave a sense of extreme dulness to the place. Just then her explorations and discoveries were cut short by a knock at the door, and on it entered a woman carrying a tray holding a cup of tea. Rosalie, who understood nothing of this sort of thing, stared at it and the bearer.
“I’m quite better now, thank you,” she said, shaking her head. “I was a little tired last night. I’d rather not have my breakfast in bed, if you don’t mind.” “This is not your breakfast,” said the other, in a voice so well modulated that many seemingly more exalted might have envied it. “Oh, what is it?” said Rosalie, standing still with her hands behind her looking at it. “A cup of tea to help you to dress.” She had the sweetest voice imaginable. Rosalie thought it the saddest she had ever heard. “I shan’t be ten minutes dressing,” she replied decidedly. “Quite an hour, I should say,” replied the other. “Oh!” gasped Rosalie. Then she clapped her hands together, caught up the flowing robe and skipped across the room to the bed. “If I’m not dressed in ten minutes, my name’s not Rosalie Paleaf.” Then with a sudden change to alarm in her manner, she turned round, growing alternately hot and cold. “I say, where are my things? I can’t see them anywhere.” “I took them away last night. There are your clothes for the day.” And she directed her attention to a chair on which some very pretty and expensive lingerie was laid. Rosalie looked at it, then drew herself up. “I want my own clothes,” she said. “These are too good for me; the others might be poor, but they were my own.” “I am afraid you cannot have them; you must dress in these.” The tears rose in Rosalie’s eyes. “I want my own clothes,” she said again. “Auntie and I cut and made them together. They were the last pair of stockings that she ever knit.” There was no answer. “Won’t you bring them back?” said Rosalie at last, the tears still standing in her eyes. “I am afraid it is against the rules of the house.”
Then Rosalie got up with a sigh, and prepared to get inside the first garment. “There is your bath first.” “I never bath in the morning; I always leave that till night.” “I think you had better do that which is customary.” Again Rosalie sighed, and followed her tormentress to an adjoining bath-room. And so it took her well on into the hour before she was dressed, ready to leave the bedroom. Mariana, who stayed to help her, insisted on arranging her hair, and after all arranged it much more becomingly than Rosalie herself had ever done. But the black robe with its red silk facings, that fitted her companion so becomingly, suited her not at all. The fit was as perfect as it could be, but otherwise she looked quite out of place in it. Breakfast was served on the same floor as that on which her bedroom was—three rooms away. All this portion of the house evidently looked out on to nothing better than the wall mentioned before; but the beauty of the interior compensated for outside gloom. Rosalie was charmed with everything she saw, though somewhat awe-struck, and she took her breakfast shyly from the hands of what she described to herself as the handsomest man she had ever seen. She also made a mental note that he must be brother to the man she saw downstairs. Rosalie had not gone all this time without grateful remembrance of that ordinary gift she had come to possess; but somehow there was some vague, indescribable thing in her surroundings that took away a full appreciation. She was longing to be outside, to talk with people more like herself, not all in black with red silk facings and knee breeches, and voices modulated to a soft perfection. Rosalie’s voice was sweet, but it was not the sweetness found in theirs. Hers was the outcome of expression, theirs of classical harmony. But how was she to get away? She dare not ask Mariana, for she was getting an uncomfortable idea that Mariana, from no ill motive, always thwarted and opposed her. So, watching her opportunity, she escaped and passed down the spiral staircase.
In the big hall below all was silent as death. Evidently no one was about. She ran across to the big doors with a palpitating heart—outside them was freedom, she scarcely knew from what. Alas! Another hand had touched the large glass handle before her own. “Your card, madam. Your passport out.” “I have none. I shall not be away five minutes.” “I am afraid you cannot go.” “But I must go.” There was no answer. Exasperated, Rosalie stood and faced him. “You let me in, and you can let me out.” “The orders are that you are not to pass.” “Whose orders?” “The master’s.” “Then take me to him.” “He is engaged at present.” “I’ll go myself, then.”
CHAPTER VII A DEBT OF GRATITUDE As Rosalie passed along the corridor her sudden decision was sealed by growing annoyance and a longing, almost amounting to fear, to get away. With scarcely a pause she knocked upon the door, that door through which she entered last night. Without stopping she opened it. Mr. Barringcourt was there alone, at a table littered with papers, writing. He was indeed busy and engrossed, for on her entrance he did not raise his head, till accosted by her voice, and then he looked up sharply enough. “You!” said he, bringing his eyebrows together in that dark frown which Rosalie had seen last night, and seeing had never forgotten. “Yes. I want to go out.” “Impossible!” said he, with an impatient gesture of his hand, and returned to the paper. “I want to go out,” she repeated. “And you have no right to stop me.” “In my own house I have every right. Go away, you are interrupting me.” “So are you interrupting me.” He laughed, not altogether kindly, and looked up at her again. “That is little short of impudent.” “I don’t care. I want to go out, and if you won’t give me leave, I shall take it.” “Take it then, by all means.” “That man at the door won’t let me.”
“Knock him down. It will be one way of surmounting the difficulty.” “He is such an elephant. I disliked him the very first time I saw him,” she replied with energy, and as much simplicity as the truth occasioned. “Well, go away and fight it out with him; watch the door, and bounce out when he’s not looking.” “I won’t do anything so undignified. I shall make friends with the kitchen people, and creep out that way.” “The kitchen door leads into the garden, and the walls are high, and the gate is locked. I keep the key myself, to ensure no one getting to the stables.” “Then give me leave to go out at the front.” “Now, why should you want to go out at the front? You have as beautiful a home as you could possibly wish for. What more can you want?” “Fresh air and human beings.” “You have them here.” She shook her head. The tears rose in her throat, and were very hard to choke down again. “It’s the dismallest place I ever came to; and I’m no use. The people here always contradict me.” “You are the first person who has ever complained of them; and your opinion goes for nothing, your own conduct leaves so much to be desired.” “In what way?” “In my time I have experienced much ingratitude, but never any quite to equal yours.” “I—ungrateful?” “Most decidedly!” “What are you wanting from me?” “Quiet submission.” Rosalie’s eyes opened wide, her lips parted; her expression was one of unfeigned surprise.
“What’s that?” “To do what you’re told quietly. Now you know, there is no excuse for your not complying.” “But to submit means to stay here.” “Of course!” “But I can’t. Oh, I can’t really! Anything but that.” “Nothing but that. You come to me with the most unusual request, and I am fool enough to put myself out of the way for you. Then you expect to go away, or rather slip away, without any more words about repayment. And when you are brought back, all this squalling.” “Nice people are quite content with ‘Thank you.’” “I’m not nice, and ‘Thank you’ never appeals to me.” “But if I stay here I can do nothing.” “Yes, you can mope.” “In return for a tongue?” “Why not? It would be the height of self-sacrifice, and the perfection of thanksgiving.” Her serious eyes met his thoughtfully. “Do you really wish me to stay here?” “I not only wish, but am determined on it.” “Then my self-sacrifice can never be spontaneous.” “You mean you are changing your mind. You are wishful to stop?” “Not wishful, but if you want it, I’ll—I’ll try to settle down more cheerfully. After all, it’s only just.” “That is so.” “Shall I often see you?” “Never. I am not fond of inflictions.” He spoke so drily, and the words were so unkind, that Rosalie’s wistful face grew paler. Yet still she argued to herself it would be selfish to wish to be free, to have a tongue and everything. And after all, the stranger was so clever that he must of necessity know best. “Will you let me out just for an hour?” she asked at length, with a voice greatly subdued from the first clamorous outburst. “Not for an hour.”
“But I have an aunt, and she is dead. I shouldn’t like strangers to take what once belonged to her.” “Where is your uncle?” “He is dead too.” “Your people?” “I have none.” “Where then, in the name of all the devils in Lucifram, do you intend to go to?” “I thought when people knew I had miraculously come by a tongue they would—” “Ah! I thought as much. You want to behave with all the absurdity of a hen that has laid an egg.” “Indeed!” said Rosalie, flushing. “You want to get out just to cackle.” She was silent. “You admit it?” “I admit nothing but your want of manners.” “What a waspish, vinegarish tongue yours is.” “It’s the fault of the doctor, then. If one cannot produce a sweet instrument one might as well admit oneself a failure.” “How was I to tell? Your face was so deceptive.” “Maybe so is my tongue. I was only speaking in fun. Let me out for one hour. Lend me twopence, and I will return, having spoken to no one, and in the right frame for being submissive.” For a short time he was silent. At last he said: “Promise me faithfully you will return.” “I promise you most faithfully.” “Within the hour?” “Yes.” “You understand perfectly that my reason for bringing you back is not for any personal gratification I should derive from it. It is simply so that you may not obtain any great or particular pleasure from having a prayer perfected.” “You speak plainly enough for the dullest mind.”
“I’m glad. Now you may go. And remember, come back if you have any sense of gratitude.” So Rosalie passed out again into the farther hall. “I have permission to pass,” said she at the door, and then she stood outside. It seemed to her when she reached the parapet that she had been out of the world for years. And oh! to be back in the world again! To see and hear the sights and sounds, so commonplace and ordinary, yet to her stilled ear so sweet again. Never had that terrible silent mansion struck her as so terrible till now she stood amongst the noise of work and life once more. One hour of freedom. One hour with the light, jogging world, and then to pass once more beneath the shadow—a silent spirit in a silent world. The ’bus rattled on, taking its own slow time towards that quarter of the city where she had lived. She found the upper storey empty, and none had missed her. Yesterday the doctor had told her his intention of coming for her at four o’clock to-day. It was not yet quite twelve. Each of the little rooms was now quite bare, except the tiny attic called her bedroom. In it were gathered the few trivial things she prized as belonging to days that were less dark than these. There was a necklace of coral, a collar of lace, a pair of gloves, kid, backed with astrachan, the last present her uncle ever gave her; a tiny brooch of gold, left by her aunt, and always worn by her, and but little else. One other thing she found, a book that in that planet compares nearly to our Bible. Sadly and lovingly she placed them all together, and kissed them many times, her eyes blinded with tears; and then a voice whispered: “Why go back? Go to this doctor. Tell him everything, for he is kind. None would blame you for not returning to that prison mansion, even though under a promise. It was an unfair advantage.” But Rosalie shook her head. “I must go back, because I promised. I asked everything in return for nothing. And God, in His own good time, will make the dark path plain.” The struggle gradually died, and Right conquered.
At last she was ready to go. Glancing round for the last time, she saw upon the mantelpiece a key, a solitary one upon an iron ring. “It belonged to uncle’s safe, the one that had so little in it,” she thought. She took it up. Its dull appearance suggested so much dull tragedy to her. “I’ll take it with me,” she thought, and slipped it in the pocket of her dress. Then she passed down the broad stone steps out once more into the street. Her brief holiday was over. The short hour was almost passed. She clenched her hands together, and drove back the blinding tears that struggled in her eyes. Gradually she drew nearer to the Avenue—how eagerly she had rushed there on the night before! The great black marble mansion came in view, its dusky grandeur having a certain sinister lowering to her understanding eye no different from a prison. “I wonder when I’ll walk along this street again?” she thought, and ascended the marble steps, hiding all trace of past emotion.
CHAPTER VIII A BOOK OF INSPIRATION “The master wished to speak to you when you returned,” the attendant at the door said to her when he answered it. Rosalie crossed the hall, feeling that vague sense of satisfaction that generally accompanies honesty, and which at times appears so poor a recompense. This time on knocking she waited for the answer. When it came she opened the door and entered. Mr. Barringcourt was in the act of filing papers, and generally tidying up the littered table. “You are quite punctual,” said he. “And what is more, astoundingly honest.” “You did not expect I should return, then?” “No! Honestly speaking, I thought I had seen the last of you.” She shook her head. “Gratitude brought me back at the expense of inclination.” “You should have yielded to temptation, and run away.” “Perhaps my action in returning was not quite so commendable as you think. I was much tempted to run away, and then—” “What?” “I could find no place to go to.” “You have no appreciative friends?” “Not one.” “The doctor?” Rosalie looked up quickly, and flushed. “Why do you speak of him?”
“I’m sure I don’t know,” he answered drily; “I believe I was meaning myself.” “Oh—yes—of course,” stammered Rosalie. “I thought you meant Dr. Kaye.” “Then you had notions of appealing to him?” Rosalie laughed. “You are not the pleasantest of companions.” “You might as well make a confidant of me. I am the only one you will find for some time.” “Well, yes, then,” she answered, looking across at him with a timid glance. “I thought of running to the doctor, informing him you intended making a prisoner of me in a free city, and asking him to give me the benefit of his protection and advice.” “And you thought better of it?” “You told me if I was grateful I should return. I was grateful, and though there seems something very topsy-turvy about the recompense you ask for, there is something in it that appeals to my sense of justice.” “That is why you came back?” “There is no other reason.” Mr. Barringcourt all this time had been sitting in his chair by the table. Rosalie was standing at the farther side of it. Now he got up and walked over to the fireplace, where the fire was burning brightly. “What is your name?” he asked. “Rosalie Paleaf.” “Brought up by an aunt and uncle?” “Yes.” “Always dumb, and therefore very much out of the world?” “Yes.” “Where did you learn the little bit of knowledge you possess?” “I listened to it. I was not deaf, you know.” “Could you read?” “Yes, I can read. That is how I used to spend most of my time.” “Travels, novels, or biography?”
“A little bit of both—all three, I mean. ‘The Life of Krimjo on the Desert Island,’ which was my favourite, contained a little of all, I think.” “Ally Krimjo was only make-belief,” said he ruthlessly. “Indeed he wasn’t! He had gone through everything he spoke about, the shipwreck and the loneliness, the savages and everything. Make-belief! Oh, Mr. Barringcourt, have you ever really read it through?” “Yes, at the time it was written.” Here Rosalie laughed again triumphantly. “That shows you don’t know the book I’m talking about at all. The man who wrote it lived hundreds of years ago. Quite three hundred, I should say.” “At that rate I must be mistaken. Then if you are so fond of travel and biography, I have some volumes here all on that subject, written, too, about the time you speak of. You will have a great deal of time lie heavy on your hands; perhaps you would like some?” Rosalie looked dubious, and her eyes travelled to the imposing- looking book-shelves. “I never found anyone quite to come up to Ally Krimjo,” she replied regretfully. “You refuse my offer?” “Not if you give me something interesting. But as a rule I don’t like biographies, because the people always die. Now, Ally Krimjo—” “You’re quite right,” said Mr. Barringcourt grimly. “Ally Krimjo hasn’t died, so he deserves to live. Have you the Book of Divine Inspiration?” “Oh, yes! I don’t suppose there’s anyone without that?” “Here’s one with pictures; look at it.” He took down from a shelf a heavy and ponderous volume of the Book of Divine Inspiration, as written and compiled in the planet Lucifram, and carried it without the least apparent effort to the table. “Now come and look at the pictures. I’ll show you a few, and then you can take it away with you and look at the rest.”
He opened it at the first page—the frontispiece. It was a picture of the Golden Serpent, so lifelike that its appearance was most startling. The book, likewise, must have possessed the property of magnifying all contained in it, for suddenly the head and coils and tails seemed to enlarge to the same gigantic size as that within the temple. “I don’t like it. Don’t show me any more of that book,” Rosalie said. “But why?” he asked, with apparent surprise. “Oh! I don’t know,” she answered, almost whispering. “It’s the Serpent. I don’t like it.” “But you are the young lady who was kissing its head, and throwing your arms around it.” “Yes, I know. That was because I did not understand.” “And now?” “Oh, now! I think it’s cruel and deceitful.” “That’s nothing short of blasphemy. The Serpent is a god!” “Do you believe that?” she asked, suddenly looking up, and fixing his eyes with a look as keen as it was serious. Two pairs of eyes, dark and light, each encountered one another— each trying to read the other’s secret—and both for once inscrutable, dark and light alike. “Yes. I’ve got a pretty good mental digestion; it can take most things,” he said, the corners of his mouth curving into a smile. “Look! Miss—Miss—What’s your name, by the way?” “My name is Rosalie—Rosalie Paleaf.” “Well now, Miss Paleaf, let us turn to the second picture.” Reluctantly she turned round once more, to behold a forest jungle, as fine and beautiful a scene as one could wish. Its size and realism made her put out her hand to pull a twig of feathery foliage, when suddenly she was startled to see beneath it a pair of eyes, wild and yet intelligent, gleaming out at her. It was an animal shaped and sized much like a monkey. Behind it was another of the same kind, a partner in its joys and sorrows evidently. Rosalie sprang back. “Look at that hideous thing!” she cried in horror, pointing to it. Then recollecting herself, she said, with an effort at more self-control
and appreciation: “Are—are they extinct now?” “I don’t know, I’m sure. What would you say?” “I sincerely hope so, I’m sure. Put it away. There is something uncanny about that book. That creature startled me.” “It’s an acquired taste. Here we come to another.” He had turned onward to a third picture, in which was shown a woman sitting on the roots of a tree, the expression of her face long and uncompromising, full of discontent. She wore no clothing, but her long and silky hair was sufficient covering. She was of no particular beauty, and her expression of discontent, mingled with curiosity, subtly introduced, and having little intelligence to enlighten it, gave the girl a feeling of repugnance. In one hand she held a fruit of brilliant scarlet; a mouthful was being eaten, and its taste did not seem altogether to her liking. “What do you think of this?” “I like it very little better. The man who painted it, judging from her face, understood human nature, and had very little mercy for it.” “There you are mistaken. It is a caricature,” he answered softly, “painted one day by a man, and sent to his dearest friend—a woman.” “But she is eating a tomato.” “Of course! Let us continue.” The next picture showed this same woman standing beside a man who sat upon a rock cracking nuts with his teeth. As Rosalie looked the scenes began to move and become lifelike, pretty much in the same way as a cinematograph. At first the man did not perceive his companion, but turning suddenly, in the act of taking a broken shell from his mouth, he saw her holding the scarlet fruit, from which she had taken no more than two fair mouthfuls. On seeing this his jaw dropped, his eyes expanded. Thin, far-away voices came from the picture, aiding the illusion. “What for did you that?” said he, in a voice devoid of beauty and expression. “To find out,” she replied, in the same manner. “But we die—we die—if we eat fruit of blood colour!” he cried, with superstitious horror in his voice.
“We no die, we live and grow fat. I eat, I live; but I miss something.” “What?” “I know not. Eat, and tell me.” Her look was cunning. “I dare not.” “It is the best of all kinds—but for one thing.” “And what is dat?” “Eat, and tell me. You be my faithful love.” Gingerly he took it in his hand, applied it reluctantly to his lips, sucking the juice alone. “It wants—” His low forehead wrinkled. He could not formulate his thoughts. “What?” “It wants—” And then all round a million voices echoed: “It wants but salt!” “Salt!” he shouted, drowning the harmonic voices in his new discovery. Hereupon the woman fell upon her knees, and almost worshipped him, kissing his hands and feet, weeping tears of pleasure on them. “Scrape me some up,” he uttered, taking advantage of her low position. She did it with her finger-nails. “Now stand back whilst I eat it.” “But I—I found it.” “Stand back, goose, and watch me eat.” “I found it first,” she whimpered. “Here’s a seed—that’s all you’re worth,” he answered. “Now I go to find more,” said he, jumping up valiantly. “You bake bread and get me butter for when I return.” “I come too!” she cried. “You eat the whole while I worky work.” “Fool—toad—weasel—monkey! bake me the bread, or I your neck am breaking!”
And with that they disappeared from the page. Only the picture in its first stage remained visible. “That’s not pretty at all,” said Rosalie. “Few things are in real life,” he answered. “But that was caricature.” “Not in the way you think. It was caricature, I grant, but with a difference.” “Yes. I don’t think the eating of salt with tomato could make a man really superior, do you?” “No; but it was the fact that he discovered salt.” “But he didn’t. He was as ignorant as she till the voices whispered it.” “Nevertheless, he caught the first sound.” “Yes, of course,” said Rosalie thoughtfully. Here Mr. Barringcourt laughed. “You do not appreciate its true absurdity,” he said; “but that, maybe, is scarcely necessary. Now, that picture, or series of pictures, was painted by a woman, and sent to the man who had sent her the first.” “But how about the voices?” “Oh! she was no ordinary woman, by any means.” “Was she quarrelling with the man?” “No. They were amusing each other in wet weather.” “They paint most beautiful scenery, but I don’t like their men and women.” “You are not intended to. Now, shall we go on?” “No; I’d rather not, really. It gives me headache, and I’ve had it ever since yesterday afternoon, except for that little bit after you had healed me.” “You are tired of the Book of Divine Inspiration?” “I’m tired of the pictures; they are no better than caricatures and skits. I don’t think that’s a good book to keep in a house at all.” “You astound me! Were you not brought up to worship the Serpent?”
“Yes; but the Serpent disappointed me.” “I see. You only worship a God who is content to spoil you?” She shook her head. “I don’t know,” she said. “Perhaps I’ll settle down again before long.” “I hope so. Has it ever struck you, Miss Paleaf, how completely you are in my power?” “No,” she answered, looking at him quickly. “Well, you know, I found you in the temple, in the Holiest Place— the place forbidden to women. Do you know what the punishment for that transgression is?” “No.” “To have your tongue torn out by the roots.” “Impossible!” “Not in the least. In this one interview with me you have said enough against the Serpent to set all its scales and coils bristling, and its fangs working.” “I have said nothing.” “‘Cruel and deceitful,’ were not those your words?” “Yes; but to tear my tongue out would not be to prove it otherwise. The Serpent’s wisdom should assert itself and prove the opposite. You were also in the Holiest Place.” “Of course; but for a man the offence is not so capital.” “Tomatoes and salt,” said Rosalie, and she laughed. He laughed also. “Your impudence is only beaten by your ignorance.” “As often as I offend solely with my tongue, you must take the blame yourself. I think you must have oiled the wheels too freely.” “It is a good thing you have no relatives, Miss Paleaf; they would have missed you, disappearing so suddenly.” “Under the circumstances, I suppose it is.” “Were you happy with them?” “Oh, yes! As happy as the day, when we were in prosperity. But this last year has been nothing but shadow and poverty, and I don’t
Welcome to our website – the perfect destination for book lovers and knowledge seekers. We believe that every book holds a new world, offering opportunities for learning, discovery, and personal growth. That’s why we are dedicated to bringing you a diverse collection of books, ranging from classic literature and specialized publications to self-development guides and children's books. More than just a book-buying platform, we strive to be a bridge connecting you with timeless cultural and intellectual values. With an elegant, user-friendly interface and a smart search system, you can quickly find the books that best suit your interests. Additionally, our special promotions and home delivery services help you save time and fully enjoy the joy of reading. Join us on a journey of knowledge exploration, passion nurturing, and personal growth every day! testbankmall.com

More Related Content

PDF
Test Bank for Perinatal and Pediatric Respiratory Care, 3rd Edition: Walsh
byswenknayerhs
 
PDF
Test Bank for Perinatal and Pediatric Respiratory Care, 3rd Edition: Walsh
byalmagdmegouo
 
PDF
Test Bank for Perinatal and Pediatric Respiratory Care, 3rd Edition: Walsh
byzarzalekicg4
 
PDF
Test Bank for Perinatal and Pediatric Respiratory Care, 3rd Edition: Walsh do...
bymilisluites
 
PDF
Test Bank for Perinatal and Pediatric Respiratory Care, 3rd Edition: Walsh
bygandulsarzo
 
PDF
Test Bank for Perinatal and Pediatric Respiratory Care, 3rd Edition: Walsh
bysolcasclavo
 
PPTX
PEDIA-FINAL 1st year topic in BS Nursing pptx
byKninteLoyu
 
PPTX
Neonate & The Physiological Transition - Dr. Vannala Raju
byVannalaRaju2
 
Test Bank for Perinatal and Pediatric Respiratory Care, 3rd Edition: Walsh
byswenknayerhs
 
Test Bank for Perinatal and Pediatric Respiratory Care, 3rd Edition: Walsh
byalmagdmegouo
 
Test Bank for Perinatal and Pediatric Respiratory Care, 3rd Edition: Walsh
byzarzalekicg4
 
Test Bank for Perinatal and Pediatric Respiratory Care, 3rd Edition: Walsh do...
bymilisluites
 
Test Bank for Perinatal and Pediatric Respiratory Care, 3rd Edition: Walsh
bygandulsarzo
 
Test Bank for Perinatal and Pediatric Respiratory Care, 3rd Edition: Walsh
bysolcasclavo
 
PEDIA-FINAL 1st year topic in BS Nursing pptx
byKninteLoyu
 
Neonate & The Physiological Transition - Dr. Vannala Raju
byVannalaRaju2
 

Similar to Test Bank for Perinatal and Pediatric Respiratory Care, 3rd Edition: Walsh

PPTX
Neonatal Physiology and Prematurity.pptx
byAjJunebug
 
PPTX
Essentials of Neonatal Resuscitation: NRP algorithm
byMOHD MUJAHED RIZWAN
 
PPTX
HNS 273 slides-part 1.pptx
bytecklaNgotie
 
PPT
basics of neonatology for paediatric anaesthetist.ppt
byPriyankaKarnik2
 
PPT
To T Transition at Birth for Health Care Workers.ppt
byMedicalSuperintenden19
 
PPTX
Common neonatal conditions for obstetrical professional
byZelalemDawit
 
PPT
neonatal physiology and transition period
byanu_radha1209
 
PPTX
CTG INTERPERITATION POWERPOINT PRESENTATION
byaymanbeni89
 
PPTX
Neonatal physiology , respiratory adaptation in the neonate
byVidhiPatel223
 
PPTX
NEONATAL RESPIRATORY CARE FROM A PHYSIO POV.pptx
byHanineHassan2
 
PDF
Neonatal resuscitation [autosaved]
byBabu Bhandari
 
PPT
Newborn.pptsczadcsczxcvxZCVsDAgargsfgsGSDVsdv
byshareefamedico
 
PDF
_OB Finals 24.pdf notes for pregnant women
bymikolwarschaw
 
PPTX
6._Baby_at_Risk_-_KOROS_E_1.pptx
bytarustarus
 
PPTX
Featl transition to neonatal period. ppt.pptx
bysaeedapkli
 
PDF
Normal labor
byFahad AlHulaibi
 
PPTX
Assessment of Mother, Fetus and Newborn with.pptx
bydrshonarkar
 
PPTX
Antenatal fetal monitoring
byMahmoud zakherah
 
PPTX
Fetal surveillance
byEyob Habtamu
 
PDF
The Newborn Lung Neonatology Questions And Controversies 1st Edition Eduardo ...
bylabiksherfbc
 
Neonatal Physiology and Prematurity.pptx
byAjJunebug
 
Essentials of Neonatal Resuscitation: NRP algorithm
byMOHD MUJAHED RIZWAN
 
HNS 273 slides-part 1.pptx
bytecklaNgotie
 
basics of neonatology for paediatric anaesthetist.ppt
byPriyankaKarnik2
 
To T Transition at Birth for Health Care Workers.ppt
byMedicalSuperintenden19
 
Common neonatal conditions for obstetrical professional
byZelalemDawit
 
neonatal physiology and transition period
byanu_radha1209
 
CTG INTERPERITATION POWERPOINT PRESENTATION
byaymanbeni89
 
Neonatal physiology , respiratory adaptation in the neonate
byVidhiPatel223
 
NEONATAL RESPIRATORY CARE FROM A PHYSIO POV.pptx
byHanineHassan2
 
Neonatal resuscitation [autosaved]
byBabu Bhandari
 
Newborn.pptsczadcsczxcvxZCVsDAgargsfgsGSDVsdv
byshareefamedico
 
_OB Finals 24.pdf notes for pregnant women
bymikolwarschaw
 
6._Baby_at_Risk_-_KOROS_E_1.pptx
bytarustarus
 
Featl transition to neonatal period. ppt.pptx
bysaeedapkli
 
Normal labor
byFahad AlHulaibi
 
Assessment of Mother, Fetus and Newborn with.pptx
bydrshonarkar
 
Antenatal fetal monitoring
byMahmoud zakherah
 
Fetal surveillance
byEyob Habtamu
 
The Newborn Lung Neonatology Questions And Controversies 1st Edition Eduardo ...
bylabiksherfbc
 

Recently uploaded

PDF
Lehigh University Eng. Programs for Thailand
bycama23
 
PPTX
Neurodevelopmental Learning Needs .pptx
byglungelo06
 
PDF
Navigating the Age of AI- Combating Social Isolation and Building Global Peac...
byALLLIFEREGARDSMFT
 
PDF
President John Dramani Mahama has declared three days of national mourning fo...
bynservice241
 
PDF
GIÁO ÁN KẾ HOẠCH BÀI DẠY TIẾNG ANH GLOBAL SUCCESS LỚP 12 (CẢ NĂM) THEO CÔNG V...
byNguyen Thanh Tu Collection
 
PPTX
Cartoon Revisions and Advertisement Grade 10
byBathabile Ngcobo
 
PPTX
ZULU METHODOLOGY 3B MICRO LESSON PRESENTATION.pptx
bySiphokazi Ncobela
 
PPTX
Prometheans finals ppt arambh.pptx
byPrometheans Quiz Club
 
PDF
Unit 4 Clustering_K-means_K-medoid_KNN.pdf
byKanchanPatil34
 
PDF
Opthalmoscope ppt-pdf-notesdownload .pdf
byAnmol Singh
 
PDF
47 ĐỀ CHÍNH THỨC THI CHỌN HỌC SINH GIỎI CÁC TỈNH MÔN TIẾNG ANH LỚP 8 THCS NĂM...
byNguyen Thanh Tu Collection
 
PPTX
Presentation one The History of Eugenics
bymbuyisaandiswa81
 
PDF
BED 105-B- Orientation - BEd. First Year - 2025
byMonika Tayade
 
PDF
Pragya 6th Sense (P6S) – 4th Edition | Open General Flagship Quiz 2025
byPragya - UEM Kolkata Quiz Club
 
PPTX
Discharge procedure.................pptx
byAneetaSharma15
 
PDF
20th C Landscape architects - Noguchi & Burle marx.pdf
byAr.Asna
 
DOCX
PHYSIOLOGY NOTES - Dr. SUDHADEVI SADANANDAN
byDr. Sudhadevi Sadanandan
 
PDF
Heat-Transfer-in-Nature.pdf/7th class new ncert/by k sandeep swamy/samyans ed...
bySandeep Swamy
 
PPTX
Isikhangisi .pptx....ukubaluleka kokwazi isikhangiso.
byKwanele28
 
PPTX
Klosek, Teremi, and Wolfson "AI Essentials: From Tools to Strategies: A 2025 ...
byNational Information Standards Organization (NISO)
 
Lehigh University Eng. Programs for Thailand
bycama23
 
Neurodevelopmental Learning Needs .pptx
byglungelo06
 
Navigating the Age of AI- Combating Social Isolation and Building Global Peac...
byALLLIFEREGARDSMFT
 
President John Dramani Mahama has declared three days of national mourning fo...
bynservice241
 
GIÁO ÁN KẾ HOẠCH BÀI DẠY TIẾNG ANH GLOBAL SUCCESS LỚP 12 (CẢ NĂM) THEO CÔNG V...
byNguyen Thanh Tu Collection
 
Cartoon Revisions and Advertisement Grade 10
byBathabile Ngcobo
 
ZULU METHODOLOGY 3B MICRO LESSON PRESENTATION.pptx
bySiphokazi Ncobela
 
Prometheans finals ppt arambh.pptx
byPrometheans Quiz Club
 
Unit 4 Clustering_K-means_K-medoid_KNN.pdf
byKanchanPatil34
 
Opthalmoscope ppt-pdf-notesdownload .pdf
byAnmol Singh
 
47 ĐỀ CHÍNH THỨC THI CHỌN HỌC SINH GIỎI CÁC TỈNH MÔN TIẾNG ANH LỚP 8 THCS NĂM...
byNguyen Thanh Tu Collection
 
Presentation one The History of Eugenics
bymbuyisaandiswa81
 
BED 105-B- Orientation - BEd. First Year - 2025
byMonika Tayade
 
Pragya 6th Sense (P6S) – 4th Edition | Open General Flagship Quiz 2025
byPragya - UEM Kolkata Quiz Club
 
Discharge procedure.................pptx
byAneetaSharma15
 
20th C Landscape architects - Noguchi & Burle marx.pdf
byAr.Asna
 
PHYSIOLOGY NOTES - Dr. SUDHADEVI SADANANDAN
byDr. Sudhadevi Sadanandan
 
Heat-Transfer-in-Nature.pdf/7th class new ncert/by k sandeep swamy/samyans ed...
bySandeep Swamy
 
Isikhangisi .pptx....ukubaluleka kokwazi isikhangiso.
byKwanele28
 
Klosek, Teremi, and Wolfson "AI Essentials: From Tools to Strategies: A 2025 ...
byNational Information Standards Organization (NISO)
 

Test Bank for Perinatal and Pediatric Respiratory Care, 3rd Edition: Walsh

  • 1.
    Test Bank forPerinatal and Pediatric Respiratory Care, 3rd Edition: Walsh download pdf https://testbankmall.com/product/test-bank-for-perinatal-and-pediatric- respiratory-care-3rd-edition-walsh/ Visit testbankmall.com today to download the complete set of test banks or solution manuals!
  • 2.
    We have selectedsome products that you may be interested in Click the link to download now or visit testbankmall.com for more options!. Test Bank for Comprehensive Perinatal and Pediatric Respiratory Care 4th Edition by Whitaker https://testbankmall.com/product/test-bank-for-comprehensive- perinatal-and-pediatric-respiratory-care-4th-edition-by-whitaker/ Test Bank for Neonatal and Pediatric Respiratory Care 5th Edition by Walsh https://testbankmall.com/product/test-bank-for-neonatal-and-pediatric- respiratory-care-5th-edition-by-walsh/ Test Bank for Neonatal and Pediatric Respiratory Care 4th Edition Brian K Walsh Download https://testbankmall.com/product/test-bank-for-neonatal-and-pediatric- respiratory-care-4th-edition-brian-k-walsh-download/ Solution Manual for A Second Course in Statistics: Regression Analysis, 8th Edition, William Mendenhall, Terry T. Sincich https://testbankmall.com/product/solution-manual-for-a-second-course- in-statistics-regression-analysis-8th-edition-william-mendenhall- terry-t-sincich/
  • 3.
    International Management Culture,Strategy, and Behavior Luthans 9th Edition Test Bank https://testbankmall.com/product/international-management-culture- strategy-and-behavior-luthans-9th-edition-test-bank/ Test Bank for Critical Thinking 12th Edition https://testbankmall.com/product/test-bank-for-critical-thinking-12th- edition/ Test Bank for Health Psychology Biopsychosocial Interactions 8th Edition Edward P Sarafino Download https://testbankmall.com/product/test-bank-for-health-psychology- biopsychosocial-interactions-8th-edition-edward-p-sarafino-download/ Test Bank for Essentials of Dental Radiography, 9th Edition : Thomson https://testbankmall.com/product/test-bank-for-essentials-of-dental- radiography-9th-edition-thomson/ Solution Manual for Selling Today, 12/E 12th Edition : 013325092X https://testbankmall.com/product/solution-manual-for-selling- today-12-e-12th-edition-013325092x/
  • 4.
    Test Bank forManagerial Accounting for Managers, 5th Edition, Eric Noreen, Peter Brewer, Ray Garrison https://testbankmall.com/product/test-bank-for-managerial-accounting- for-managers-5th-edition-eric-noreen-peter-brewer-ray-garrison/
  • 5.
    Description: With the in-depthcoverage you need, this text helps you provide quality treatment for neonates, infants and pediatric patients. It discusses the principles of neonatal and pediatric respiratory care while emphasizing clinical application. Not only is this edition updated with the latest advances in perinatal and pediatric medicine, but it adds a new chapter on pediatric thoracic trauma plus new user-friendly features to simplify learning. 1. Front Matter 2. Dedication 3. Contributors 4. Reviewers 5. Preface 6. AUDIENCE 7. New to this Edition 8. LEARNING AIDS 9. Evolve Resources—http://evolve.elsevier.com/Walsh/perinatal/ 10. For the Instructor 11. For Students 12. ACKNOWLEDGMENTS 13. Section I Fetal Development, Assessment, and Delivery 14. Chapter 1 Fetal Lung Development 15. LEARNING OBJECTIVES 16. STAGES OF LUNG DEVELOPMENT 17. Embryonal Stage 18. TABLE 1-1 Classification of Stages of Human Intrauterine Lung Growth 19. Pseudoglandular Stage 20. FIGURE 1-1 Embryonal stage of lung development: the trachea and major bronchi at A to C, 4 weeks; D and E, 5 weeks; F, 6 weeks; G, 8 weeks. 21. Canalicular Stage 22. FIGURE 1-2 Canalicular stage of lung development at 22 weeks of gestation. A terminal bronchiole (bottom left) leads into a prospective acinus. Note that branches are sparse. 23. Saccular Stage 24. Alveolar Stage 25. POSTNATAL LUNG GROWTH 26. FIGURE 1-3 Saccular stage of lung development at 29 weeks of gestation. Secondary crests (arrows) begin to divide saccules into smaller compartments.
  • 6.
    27. FIGURE 1-4Alveolar stage of lung development at 36 weeks of gestation. Note the double capillary network (solid arrows, center and right) and the single capillary layer (arrow at left). 28. FIGURE 1-5 Alveolar stage of lung development at 36 weeks of gestation: thin-walled alveoli are present. 29. FACTORS AFFECTING PRENATAL AND POSTNATAL LUNG GROWTH 30. ABNORMAL LUNG DEVELOPMENT 31. PULMONARY HYPOPLASIA 32. ALVEOLAR CELL DEVELOPMENT AND SURFACTANT PRODUCTION 33. FETAL LUNG LIQUID 34. ASSESSMENT QUESTIONS 35. References 36. Chapter 2 Fetal Gas Exchange and Circulation 37. LEARNING OBJECTIVES 38. MATERNAL-FETAL GAS EXCHANGE 39. FIGURE 2-1 Implanted human embryo, approximately day 28, showing the relationship of the chorion, amnion, and chorionic villi. The umbilical cord and tail are difficult to differentiate in this view. 40. Box 2-1 Origin of the Various Tissue Systems From the Three Embryonic Germ Layers* 41. ECTODERM 42. MESODERM 43. ENDODERM 44. CARDIOVASCULAR DEVELOPMENT 45. Early Development 46. TABLE 2-1 Timetable of Significant Events During Fetal Heart Development 47. Chamber Development 48. FIGURE 2-2 Formation of the primordial heart chambers after fusion of the heart tubes at a gestational age of 3 weeks. 49. FIGURE 2-3 A, Sagittal view of the developing heart during week 4, showing the position of the atrium, bulbus cordis, ventricles, and endocardial cushions merging from the ventral and dorsal sides. B, Traditional view of the developing heart during weeks 4 to 5, showing budding interventricular septum, fused endocardial cushions. septum primum, and the left and right atria. The ventricular septum continues to fold and grow upward between the ventricles. 50. Maturation 51. FIGURE 2-4 Frontal view of the fetal heart between weeks 5 and 6, showing the development of the four chambers nearing completion. The arrow shows the one- way path through the foramen ovale. 52. FIGURE 2-5 Frontal view (right) and side view (left) schematics of the foramen ovale. The septum primum forms the flap, and the septum secundum remains open to form the foramen ovale. The arrows show the one-way path through the foramen ovale. 53. FETAL CIRCULATION AND FETAL SHUNTS
  • 7.
    54. FIGURE 2-6A diagram of the fetal circulation, showing blood containing oxygen and nourishment moving from the placenta to the fetal heart and through the three fetal shunts: the ductus venosus, the foramen ovale, and the ductus arteriosus. 55. TRANSITION TO EXTRAUTERINE LIFE 56. ASSESSMENT QUESTIONS 57. References 58. Chapter 3 Antenatal Assessment and High-risk Delivery 59. LEARNING OBJECTIVES 60. MATERNAL HISTORY AND RISK FACTORS 61. Preterm Birth 62. Cervical Insufficiency 63. Toxic Habits in Pregnancy 64. Alcohol 65. Smoking 66. Cocaine 67. Hypertension and Diabetes Mellitus 68. Hypertension 69. Diabetes 70. Pregestational Diabetes 71. Gestational Diabetes Mellitus 72. Infectious Diseases 73. Group B Streptococcus 74. Herpes Simplex Virus 75. Hepatitis B Virus and Human Immunodeficiency Virus 76. HIV 77. HBV 78. Fetal Membranes, Umbilical Cord, and Placenta 79. Disorders of Amniotic Fluid Volume 80. Mode of Delivery 81. Breech Presentation 82. Assisted Vaginal Delivery 83. Cesarean Delivery 84. ANTENATAL ASSESSMENT 85. Ultrasound 86. FIGURE 3-1 Ultrasound picture of a fetus at 23 weeks of gestation (top), with a Doppler study of the fetal heart (bottom). Dop, Doppler; Fr, frame; Freq, frequency; PRF, pulse-repetition frequency; SV, sample volume; WF, wall filter. 87. Amniocentesis 88. Nonstress Test and Contraction Stress Test 89. FIGURE 3-2 A nonstress test recording, produced with a cardiotocograph. A, The fetal heart rate (FHR) is recorded with an ultrasound probe as changes in beats per minute (bpm) over time. B, Uterine contractions (UC) are recorded with a pressure transducer as changes in pressure (mm Hg) over time. In this case the nonstress test is reactive, indicating normal uteroplacental function. 90. Fetal Biophysical Profile 91. INTRAPARTUM MONITORING
  • 8.
    92. HIGH-RISK CONDITIONS 93.Preterm Labor 94. TABLE 3-1 Biophysical Profile Scoring 95. FIGURE 3-3 Early decelerations (coinciding with uterine contraction) are usually due to fetal head compression and pose little threat to the fetus. 96. FIGURE 3-4 Variable decelerations are the most common. They are due to cord compression and have different configurations. Repetitive severe variable decelerations are associated with increased risk of fetal hypoxia. 97. FIGURE 3-5 Late decelerations are due to uteroplacental insufficiency. They usually begin at the peak of the contraction and are associated with fetal distress. 98. TABLE 3-2 Normal Values for Fetal Scalp Blood and Umbilical Cord Blood Gases 99. Postterm Pregnancy 100. ASSESSMENT QUESTIONS 101. References 102. Chapter 4 Neonatal Assessment and Resuscitation 103. LEARNING OBJECTIVES 104. PREPARATION 105. Box 4-1 Perinatal Factors Associated With Increased Risk of Neonatal Depression 106. ANTEPARTUM (FETOMATERNAL) 107. INTRAPARTUM 108. STABILIZING THE NEONATE 109. Drying and Warming 110. FIGURE 4-1 Correct and incorrect head positions for resuscitation. 111. Clearing the Airway 112. FIGURE 4-2 Meconium aspirator, with an endotracheal tube attached to one end and a suction source attached at the other end. 113. Providing Stimulation 114. ASSESSING THE NEONATE 115. Respiration 116. Heart Rate 117. Skin Color 118. Apgar Score 119. FIGURE 4-3 Algorithm for resuscitation of the newborn. HR, Heart rate (beats/min). 120. TABLE 4-1 Apgar Scoring 121. Apgar Score in the Very Low Birth Weight Infant 122. RESUSCITATING THE NEONATE 123. Oxygen Administration 124. Ventilation 125. FIGURE 4-4 Correct technique for holding a mask to the face of a newborn. Note that fingers do not touch the neck or soft tissue under the chin. 126. FIGURE 4-5 Incorrect technique for holding a mask to the face of a newborn. Note that the fingers are touching the neck and soft tissue under the chin, causing airway obstruction.
  • 9.
    127. TABLE 4-2Advantages and Disadvantages of Three Devices for Delivering Positive-pressure Ventilation to Neonates 128. Chest Compressions 129. Medications 130. Epinephrine 131. Volume Expanders 132. Naloxone 133. Sodium Bicarbonate 134. Postresuscitation Care 135. Ethical Considerations 136. Assessment Questions 137. References 138. Section II Assessment and Monitoring of the Neonatal and Pediatric Patient 139. Chapter 5 Examination and Assessment of the Neonatal Patient 140. LEARNING OBJECTIVES 141. GESTATIONAL AGE AND SIZE ASSESSMENT 142. FIGURE 5-1 Ballard examination for estimating gestational age, using scores determined on the basis of neurologic and physical signs. 143. PHYSICAL EXAMINATION 144. FIGURE 5-2 Overview of conditions producing neonatal morbidity and mortality by birth weight and gestational age. RDS, Respiratory distress syndrome. 145. Vital Signs 146. TABLE 5-1 Normal Values for Vital Signs in the Neonatal Patient 147. General Inspection 148. FIGURE 5-3 “Waiter's tip” positioning of the left arm of an infant with brachial plexus injury from a traumatic delivery. 149. Respiratory Function 150. TABLE 5-2 Common Dermal Findings in the Neonatal Patient 151. FIGURE 5-4 Silverman scoring system for assessing the magnitude of respiratory distress. Exp., Expiratory; insp., inspiratory; retract., retraction. 152. Chest and Cardiovascular System 153. TABLE 5-3 Signs of Respiratory Distress in the Neonatal Patient 154. Abdomen 155. FIGURE 5-5 Infant with prune-belly syndrome. 156. Head and Neck 157. Musculoskeletal System, Spine, and Extremities 158. FIGURE 5-6 Infant with an open spinal defect. 159. FIGURE 5-7 Infant with myelomeningocele. 160. Cry 161. NEUROLOGIC ASSESSMENT 162. LABORATORY ASSESSMENT 163. TABLE 5-4 Laboratory Values in the Neonatal Patient 164. Box 5-1 “Red Flags” in Neonatal Patients 165. RESPIRATORY 166. CARDIAC 167. RENAL
  • 10.
    168. GASTROINTESTINAL 169. METABOLIC 170.GENERAL 171. ASSESSMENT QUESTIONS 172. References 173. Chapter 6 Examination and Assessment of the Pediatric Patient 174. LEARNING OBJECTIVES 175. PATIENT HISTORY 176. Chief Complaint 177. New Patient History 178. Box 6-1 New Patient History 179. CHIEF COMPLAINT OR PRIMARY REASON FOR VISIT 180. History of Present Illness 181. Past Medical History 182. Review of Symptoms 183. Family History 184. Social and Environmental Histories 185. Follow-up or Established Patient History 186. Box 6-2 Follow-up or Established Patient History 187. CHIEF COMPLAINT AND/OR PREVIOUS DIAGNOSIS OR PROBLEM 188. Interim History 189. Review of Key Components 190. PULMONARY EXAMINATION 191. Box 6-3 Pulmonary Examination 192. Inspection 193. TABLE 6-1 Normal Respiratory Rates in Sleeping and Awake Pediatric Patients 194. FIGURE 6-1 Head bobbing. 195. Palpation 196. FIGURE 6-2 Intercostal retractions. Soft tissue between the ribs is pulled inward (retracted) because of the extremely high negative pleural pressure. 197. FIGURE 6-3 Suprasternal retractions. Soft tissue in the suprasternal space is retracted because of high negative pressure, most often caused by the patient's attempt to breathe against an airway obstruction. 198. Percussion 199. FIGURE 6-4 Subcostal/substernal retractions. Airway obstruction results in a pulling inward of the lower costal margins. The abdomen is protruding (1), and there is a sunken substernal notch (2). See-saw movement of the chest and stomach is also present. 200. FIGURE 6-5 Technique for determining tracheal position in the older child. 201. Auscultation 202. NONPULMONARY EXAMINATION 203. Box 6-4 Nonpulmonary Examination: Findings Possibly Associated With Pulmonary Disease 204. GENERAL 205. EARS, EYES, NOSE, THROAT
  • 11.
    206. HEART 207. ABDOMEN 208.SKIN 209. EXTREMITIES 210. FIGURE 6-6 A, Normal finger viewed from above and in profile, and the changes occurring in established clubbing, viewed from above and in profile. B, The finger on the left demonstrates normal profile (ABC) and normal hyponychial (ABD) nail-fold angles of 169 and 183 degrees, respectively. The clubbed finger on the right shows increased profile and hyponychial nail-fold angles of 191 and 203 degrees, respectively. C, Distal phalangeal finger depth (DPD)/interphalangeal finger depth (IPD) represents the phalangeal depth ratio. In normal fingers, the IPD is greater than the DPD. In clubbing, this relationship is reversed. D, Schamroth sign: in the absence of clubbing, opposition of the index fingers nail-to-nail creates a diamond-shaped window (arrowhead). In clubbed fingers, the loss of the profile angle due to an increase in tissue at the nail bed causes obliteration of this space (arrowhead). 211. LABORATORY TESTING 212. Box 6-5 Laboratory Evaluation 213. THE HEALTH CARE TEAM 214. CASE STUDIES 215. CASE 1 216. Family History 217. CASE 2 218. CASE 3 219. Box 6-6 History Taking in the Pediatric Patient With Asthma 220. MANIFESTATIONS 221. AGGRAVATING FACTORS 222. ALLEVIATING FACTORS 223. ASSOCIATED CONDITIONS (REVIEW OF SYMPTOMS) 224. FAMILY HISTORY 225. ENVIRONMENTAL EXPOSURES 226. ASSESSMENT QUESTIONS 227. References 228. Chapter 7 Pulmonary Function Testing and Bedside Pulmonary Mechanics 229. LEARNING OBJECTIVES 230. DEFINITIONS 231. SPECIAL CONSIDERATIONS 232. Neonatal Testing 233. Pediatric Testing 234. Instrumentation 235. Selection of Data for Analysis 236. MECHANICS OF BREATHING IN NEWBORNS 237. FIGURE 7-1 A pneumotachometer with a pulmonary function testing (PFT) computer system. As gas flow passes through the restrictive element, the difference in pressure between P1 and P2 is converted to a flow measurement. The flow rate over time is then converted to volume measurement. 238. Lung Inflation and Transpulmonary Pressure
  • 12.
    239. NEONATAL PULMONARYFUNCTION TESTING IN THE LABORATORY 240. Measuring Static Compliance and Airway Resistance 241. Measuring Functional Residual Capacity 242. FIGURE 7-2 Volume–pressure loops of tidal breathing at various levels of functional residual capacity (FRC): a, low FRC; b, normal FRC; c, elevated FRC. 243. Helium Dilution Method 244. Nitrogen Washout Method 245. Plethysmography 246. Measuring Maximal Expiratory Flow by Rapid Thoracic Compression Technique 247. FIGURE 7-3 Partial expiratory flow–volume (PEFV) curves with identification of maximal expiratory flow at FRC (VmaxFRC), demonstrating a normal resting tidal breath and one with flow limitation. A, Normal; B, abnormal (flow limited). 248. PEDIATRIC PULMONARY FUNCTION TESTING IN THE LABORATORY 249. Standard Spirometry 250. Flow–Volume Loop 251. FIGURE 7-4 A normal standard time–volume spirometry graph, depicting the forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), and forced expiratory flow between 25% and 75% of vital capacity (FEF25-75). 252. FIGURE 7-5 Normal flow–volume loop, showing both the expiratory and the inspiratory loops. The usual flow rates are identified. Note that no forced expiratory volume in 1 second (FEV1) is evident because there is no time axis. FEF50, Forced expiratory flow at 50% of vital capacity; FVC, forced vital capacity; PEFR, peak expiratory flow rate; RV, residual volume; TLC, total lung capacity. 253. FIGURE 7-6 This expiratory flow–volume loop demonstrates the patient's failure to exhale completely to residual volume (RV). This will artificially decrease FVC and increase FEF50. 254. FIGURE 7-7 Comparison of a forced expiratory flow–volume curve starting from 100% of total lung capacity (TLC) with a curve starting at 75% of TLC. The computer software will have no way of knowing that the smaller curve was not started at 100% TLC and will start the smaller curve at zero volume. This artificially decreases FVC, PEFR, and FEF50. A, Both curves start at TLC, as displayed by the computer. B, The curves, if matched at RV, would reflect that the smaller curve was not started at full lung volume. Clinicians must do their best to ensure that the patient starts the expiratory maneuver at 100% TLC. 255. Forced Vital Capacity, Forced Expiratory Volume, and Ratio of Forced Expiratory Volume to Forced Vital Capacity 256. Forced Expiratory Flow at 25% to 75% and at 50% of Vital Capacity 257. TABLE 7-1 Pulmonary Function Measurements in Children 258. Spirometric Values 259. FIGURE 7-8 Prebronchodilator and postbronchodilator expiratory loops produced by a 5-year-old patient with asthma. The prebronchodilator curve is slightly concave with respect to the volume axis, which is not evident on the postbronchodilator curve. The FEF50 is the only prebronchodilator measurement below the expected normal range of variability; it increased by 70% after bronchodilator therapy. FEF50, Forced expiratory flow at 50% of vital capacity; FEV1,
  • 13.
    forced expiratory volumein 1 second; FVC, forced vital capacity; PEFR, peak expiratory flow rate. 260. TABLE 7-2 Characterization of Obstructive and Restrictive Patterns in Pulmonary Function Testing 261. Lung Volumes 262. FIGURE 7-9 Body plethysmography “box.” 263. FIGURE 7-10 Graphic display of the subdivisions of total lung capacity (TLC), from quiet tidal breathing on the left to maximal inhalation and exhalation on the right. ERV, Expiratory reserve volume; FRC, functional residual capacity; IC, inspiratory capacity; RV, residual volume; VC, vital capacity; VT, tidal volume. 264. Provocation Tests 265. TABLE 7-3 Positive Methacholine Challenge in a 7-year-old Girl With Chronic Cough* 266. MEASURING PULMONARY MECHANICS AT THE BEDSIDE 267. Calculated Parameters 268. Tidal Volume 269. Respiratory Frequency 270. Minute Ventilation 271. Rapid Shallow Breathing Index 272. Inspiratory and Expiratory Times 273. Lung Compliance 274. Airway Resistance 275. Time Constants 276. FIGURE 7-11 Tracing of pressure, flow, and volume over time (in seconds). Exp, Expiration; Insp, inspiration. 277. Pressure, Flow, and Volume Over Time 278. Flow–Volume Loops 279. FIGURE 7-12 Patterns of flow–volume loops. A, Normal; B, restrictive; C, obstructive. 280. FIGURE 7-13 Flow–volume loops showing various forms of airway obstruction. A, Fixed obstruction; B, variable extrathoracic obstruction; C, variable intrathoracic obstruction. 281. Pressure–Volume Loops 282. FIGURE 7-14 Pressure–volume loops demonstrating normal and decreased lung compliance. A, Normal lung compliance; B, decreased lung compliance. 283. Lung Overdistention 284. FIGURE 7-15 Pressure–volume loops demonstrating overdistention. Note the “penguin” or “bird's beak” appearance in the shape of the loops. These loops demonstrate idealized slopes (dashed lines) for change in compliance for the entire breath (C) and change in compliance in the last 20% of inspiratory pressure (C20). The C20/C ratio identifies lung overdistention. 285. Work of Breathing 286. Other Bedside Tests 287. Vital Capacity 288. Peak Expiratory Flow Rate 289. Maximal Inspiratory Pressure
  • 14.
    290. Complex BedsideMeasurements 291. SUMMARY 292. ASSESSMENT QUESTIONS 293. References 294. Chapter 8 Radiographic Assessment 295. LEARNING OBJECTIVES 296. RADIOGRAPHIC TECHNIQUE 297. FIGURE 8-1 Expiratory frontal chest radiograph shows normal decrease in left lung volume. Tooth (arrow) obstructs the right mainstem bronchus and causes air trapping in the right lung. 298. NORMAL CHEST ANATOMY 299. FIGURE 8-2 A, Left lower lobe pneumonia abuts the diaphragm, leading to nonvisualization of the normal edge of the diaphragm. The cardiac border is demarcated because the lingula (a segment of the upper lobe of the left lung) is normally aerated. B, Only the right hemidiaphragm is visualized because the left is obscured by the left lower lobe pneumonia. Major fissure appears as an edge (arrow). 300. FIGURE 8-3 Normal frontal view of the chest demonstrating the thoracic inlet (1), carina (the point at which the trachea splits into the two mainstem bronchi) (2), the aortic arch (3), and pulmonary hila (4). 301. FIGURE 8-4 Normal thymus abuts the minor fissure (arrow) and has a curved lateral margin. 302. FIGURE 8-5 A, Infant with respiratory distress syndrome on lower ventilator setting. B, Same infant on higher ventilator setting. 303. POSITIONING OF LINES AND TUBES 304. AIRWAY OBSTRUCTION 305. FIGURE 8-6 Enlarged tonsils (arrow) appear to hang down into the hypopharynx. The nasopharynx (arrowhead) is narrowed from enlarged adenoids located posterior and superior. 306. FIGURE 8-7 “Steepling” of the subglottic airway is caused by croup. 307. FIGURE 8-8 Enlarged epiglottis (arrow) appears as a “thumb” projecting into the airway. 308. FIGURE 8-9 Hypopharynx and trachea are displaced away from the cervical spine by a retropharyngeal abscess. 309. FIGURE 8-10 Edema from a coin in the upper esophagus causes marked narrowing of the adjacent trachea. The child presented with stridor and difficulty with swallowing. 310. RESPIRATORY DISTRESS IN THE NEWBORN 311. FIGURE 8-11 Even after intubation, the lungs are hypoinflated and have a granular pattern with faint air bronchograms in this infant with respiratory distress syndrome. 312. Box 8-1 Respiratory Distress in the Newborn 313. FIGURE 8-12 Large left pneumothorax appears black and outlines the partially collapsed left lung and left cardiac border (arrow). 314. FIGURE 8-13 Pneumomediastinum elevates the left lobe of the thymus to produce a “spinnaker sail” in this child, who also has a large left pneumothorax.
  • 15.
    315. FIGURE 8-14Massive pulmonary interstitial emphysema throughout the left lung causes shift of the mediastinum to the right and downward displacement of the left hemidiaphragm. 316. FIGURE 8-15 Meconium aspiration appears as a coarse asymmetric pattern. Enlargement of the heart may be secondary to fluid overload in this infant. 317. FIGURE 8-16 Group B streptococcal pneumonia presents in this infant with hyperinflation, small right pleural effusion (arrow), and hazy infiltrative pattern. 318. FIGURE 8-17 Multiple “cysts” in the left hemithorax are air-filled loops of bowel that herniated through a defect in the left hemidiaphragm. The abdomen is scaphoid from decreased bowel content. 319. ATELECTASIS 320. FIGURE 8-18 Left upper lobe collapse causes elevation of the left hemidiaphragm and crowding of the left ribs from volume loss. The cardiac and superior mediastinal borders are indistinct because of the “silhouette sign” while the diaphragm remains demarcated by the aerated left lower lobe. 321. FIGURE 8-19 Collapsed right middle lobe appears as a triangular wedge of increased density extending anteriorly and inferiorly toward the anterior chest wall and diaphragm. 322. PNEUMONIA 323. FIGURE 8-20 Round pneumonia (arrow) in the left lower lobe simulates a mass. 324. ASTHMA 325. CYSTIC FIBROSIS 326. FIGURE 8-21 Coarse interstitial markings, hyperinflation, bronchiectasis, mucous plugging (arrow), atelectasis (arrowhead), and enlarged pulmonary hila are all demonstrated in this child with cystic fibrosis. 327. FIGURE 8-22 Pneumonia was the precipitating precursor to acute respiratory distress syndrome, with densely consolidated lungs and air bronchograms (arrow). 328. ACUTE RESPIRATORY DISTRESS SYNDROME 329. CHEST TRAUMA 330. FIGURE 8-23 Trauma to the chest resulted in extensive bilateral air leaks and densely consolidated pulmonary contusions. Multiple rib fractures are present. 331. Assessment Questions 332. References 333. Chapter 9 Pediatric Flexible Bronchoscopy 334. LEARNING OBJECTIVES 335. INDICATIONS 336. Diagnostic Bronchoscopy 337. Stridor 338. Box 9-1 Indications for Flexible Bronchoscopy 339. DIAGNOSTIC 340. Airway Anatomy Evaluation 341. Bronchoalveolar Lavage and Biopsy 342. Cytopathology 343. Microbiology 344. Foreign Body Aspiration
  • 16.
    345. Hemoptysis 346. THERAPEUTIC 347.Wheeze 348. Cough 349. Radiographic Abnormalities 350. Foreign Body Aspiration 351. Hemoptysis 352. Inhalation Injury 353. Therapeutic Bronchoscopy 354. CONTRAINDICATIONS 355. Box 9-2 Contraindications to Flexible Bronchoscopy 356. ABSOLUTE CONTRAINDICATIONS 357. RELATIVE CONTRAINDICATIONS 358. EQUIPMENT 359. Flexible Bronchoscope 360. Insertion Tube 361. FIGURE 9-1 Three different sizes of pediatric flexible bronchoscopes. Top to bottom: 4.5-, 3.6-, and 2.2-mm outer diameter. Note that all scopes have similar working tube lengths. 362. Control Head and Eyepiece 363. Light Source Connector 364. Video Recording Equipment 365. PREPARATION 366. Equipment and Supplies 367. Box 9-3 Equipment and Supplies for Pediatric Flexible Bronchoscopy 368. FIGURE 9-2 Necessary equipment for basic pediatric flexible bronchoscopy includes bronchoscope, attached suction tube, 2% lidocaine jelly, lidocaine spray, three 1-ml aliquots of 1% lidocaine solution, Luken trap, gauze pads, and three to five 10-ml aliquots of normal saline for bronchoalveolar lavage. These items are placed on a clean drape on top of a portable bronchoscopy cart. 369. Patient 370. Personnel 371. PROCEDURE 372. Conscious Sedation 373. Topical Anesthesia 374. Patient Monitoring 375. Technique 376. POSTPROCEDURAL MONITORING AND COMPLICATIONS 377. EQUIPMENT MAINTENANCE 378. FIGURE 9-3 Correct placement of flexible bronchoscope in STERIS cleaning apparatus, used for chemical sterilization of the instrument. 379. COMPARISON WITH RIGID BRONCHOSCOPY 380. Assessment Questions 381. References 382. Chapter 10 Invasive Blood Gas Analysis and Cardiovascular Monitoring 383. LEARNING OBJECTIVES
  • 17.
    384. BLOOD GASSAMPLING 385. Pain Control 386. FIGURE 10-1 Arterial sites that may be used for peripheral artery puncture in infants and children. 387. Box 10-1 Indications for Blood Gas Analysis 388. Arterial Sampling Sites 389. Modified Allen's Test 390. ARTERIAL PUNCTURE 391. Procedure 392. Box 10-2 Equipment for Arterial Puncture and Blood Gas Collection 393. Contraindications 394. Complications 395. CAPILLARY BLOOD GAS SAMPLES 396. Puncture Sites 397. FIGURE 10-2 Recommended puncture sites (shaded areas) in infant's heel to obtain capillary blood for analysis. 398. FIGURE 10-3 Technique for grasping the finger for a capillary puncture, with recommended site for puncture indicated (shaded area). 399. Procedure 400. Box 10-3 Equipment for Capillary Puncture and Blood Gas Collection 401. FIGURE 10-4 Technique for stabilizing the heel for a capillary puncture. 402. Contraindications 403. Complications 404. ARTERIAL CATHETERS 405. Umbilical Artery Catheterization 406. FIGURE 10-5 An indwelling arterial line and continuous infusion/flush system used to monitor blood pressure and obtain blood gas samples. Exploded view shows a three-way stop-cock system. A, Normal position with stop-cock off to sampling port allows continuous monitoring of blood pressure and flushing of the line if using a (pig tail) flush system. B, Position to draw blood or inject flush solution to the patient with stop-cock turned off to flush solution. C, Position to flush sample port with stop-cock off to patient. All ports are closed at all intermediary positions 407. Peripheral Artery Catheterization 408. Procedure for Sampling 409. Complications 410. Measurements 411. CONTINUOUS INVASIVE BLOOD GAS MONITORING 412. FIGURE 10-6 An ex vivo in-line continuous blood gas monitor designed for use in critically ill newborn infants. 413. CENTRAL VENOUS CATHETERS 414. Monitoring Sites 415. Procedure 416. Complications 417. Measurements 418. PULMONARY ARTERY CATHETERIZATION
  • 18.
    419. FIGURE 10-7Conventional pulmonary artery (Swan-Ganz) thermodilution catheter. 420. Procedure 421. FIGURE 10-8 Examples of pressure waveform patterns at various locations in and around the heart. A, Central venous pressure; B, right ventricular pressure; C, pulmonary artery pressure; D, pulmonary capillary wedge pressure. 422. FIGURE 10-9 Pressure waveforms as the catheter travels through the right atrium (RA), right ventricle (RV), and pulmonary artery (PA), becoming wedged (pulmonary capillary wedge pressure [PCWP]). 423. Complications 424. Measurements 425. Box 10-4 Normal Pressure Values From Pulmonary Artery Catheters 426. Cardiac Output 427. TABLE 10-1 Normal Ranges of Derived Hemodynamic Parameters 428. NONINVASIVE MEASUREMENT OF CARDIAC OUTPUT AND PERFUSION 429. PATIENT INFORMATION 430. FREQUENCY 431. TABLE 10-2 Approximate Normal Range of Arterial Blood Gas Values 432. BLOOD GAS INTERPRETATION 433. Acid–Base Balance 434. Oxygenation 435. TABLE 10-3 Laboratory Values for Acid–base Disturbances 436. Box 10-5 Causes of Metabolic Acidosis 437. Box 10-6 Causes of Metabolic Alkalosis 438. Box 10-7 Causes of Respiratory Acidosis 439. LUNG DISEASE 440. IMPAIRED LUNG MOTION 441. APNEA 442. OTHER 443. Box 10-8 Causes of Respiratory Alkalosis 444. FIGURE 10-10 Oxyhemoglobin dissociation curve, illustrating the P50 value (Po2 at 50% saturation) with the effects of right and left shifts of the curve. As the curve shifts to the right, the oxygen affinity of hemoglobin decreases, more oxygen is released at a given Po2, and the P50 value increases. When the curve shifts to the left, there is increased oxygen affinity, less oxygen is released at a given Po2, and the P50 value decreases. 445. TABLE 10-4 Factors That May Shift Oxyhemoglobin Dissociation Curve 446. FIGURE 10-11 Components of oxygen delivery. 447. ABNORMAL HEMOGLOBIN 448. ASSESSMENT QUESTIONS 449. References 450. Chapter 11 Noninvasive Monitoring in Neonatal and Pediatric Care 451. LEARNING OBJECTIVES 452. PULSE OXIMETRY 453. Principles of Operation
  • 19.
    454. FIGURE 11-1Proper alignment of light-emitting diodes (LEDs) opposite the photodetector in a sensor applied to a patient's finger. 455. Application 456. FIGURE 11-2 Differences in light absorption between deoxygenated hemoglobin (0% saturation) and oxygenated hemoglobin (100% saturation) during pulsatile signals. 457. FIGURE 11-3 Pulse oximeter probe attached to a child's toe. 458. Disadvantages 459. TRANSCUTANEOUS MONITORING 460. Principles of Operation 461. Application 462. FIGURE 11-4 Transcutaneous oxygen monitor electrode placed on a child's arm. 463. Disadvantages 464. New Technology 465. FIGURE 11-5 Location of mainstream airway adapter (A) and sidestream adapter (B) in patient's airway. 466. CAPNOMETRY 467. Principles of Operation 468. Interpretation of Capnogram 469. FIGURE 11-6 Normal capnogram. 470. Detection of Ventilation Problems 471. Endotracheal Tube in Esophagus 472. Rebreathing 473. Obstructed Airway 474. Paralyzed Patients 475. FIGURE 11-7 Effect of rebreathing carbon dioxide on the capnogram. Note that the inspiratory level does not return to zero. 476. FIGURE 11-8 Capnogram with sloping alveolar plateau representative of airway obstruction. 477. FIGURE 11-9 Curare cleft in the alveolar plateau. 478. FIGURE 11-10 Stair effect on the descending limb of the capnogram indicating a potential pneumothorax. 479. Pneumothorax 480. Cardiogenic Oscillations 481. IMPEDANCE PNEUMOGRAPHY 482. FIGURE 11-11 Cardiogenic oscillations in synchrony with the ECG signal. 483. Principles of Operation 484. Application 485. FIGURE 11-12 Neonatal impedance pneumography. With the infant on a flat surface, the belt is positioned in line with the nipples. After the electrodes are placed, the belt is wrapped snugly around the infant's chest. 486. Disadvantages 487. ELECTROCARDIOGRAPHY 488. CALORIMETRY 489. Principles of Operation
  • 20.
    490. Disadvantages 491. ASSESSMENTQUESTIONS 492. References 493. Section III Therapeutic Procedures for Treatment of Neonatal and Pediatric Disorders 494. Chapter 12 Oxygen Administration 495. LEARNING OBJECTIVES 496. INDICATIONS 497. Documented or Suspected Hypoxemia 498. Evidence of Hypoxemia 499. Measurement of Oxygen Tension and Saturation 500. Clinical Signs and Symptoms 501. COMPLICATIONS 502. OXYGEN ADMINISTRATION 503. Variable-performance Oxygen Delivery Systems 504. Nasopharyngeal Catheter 505. Indications and Contraindications 506. Application 507. Hazards and Complications 508. Nasal Cannula 509. FIGURE 12-1 Infant with a neonatal nasal cannula. 510. Indications and Contraindications 511. Application 512. FIGURE 12-2 NeoHold cannula/tubing holder. The 4-cm-long strip attaches to the skin with hydrocolloid while the flap on top positions and secures the tubing in place. The clear flap allows visualization of the tubing. 513. FIGURE 12-3 Tender Grip skin fixation pad. A round base of microporous tape is applied to the infant's skin. The flap on top of the base is designed to position and secure the tubing in place. 514. Blenders and Low-flow Flowmeters 515. Inspired Oxygen Determination 516. Box 12-1 Regression Equation for Estimating Nasal Cannula Fio2 at Low Flow Rates 517. Hazards and Complications 518. Simple Oxygen Mask 519. FIGURE 12-4 Infant with a simple oxygen mask. 520. Indications and Contraindications 521. Application 522. Hazards and Complications 523. Reservoir Masks 524. FIGURE 12-5 Pediatric patient with a partial-rebreathing mask, a type of reservoir mask. 525. Partial-rebreathing Mask 526. Nonrebreathing Mask 527. Fixed-performance Oxygen Delivery Systems 528. Air-entrainment Mask
  • 21.
    529. FIGURE 12-6Pediatric patient with an air-entrainment mask. 530. Indications and Contraindications 531. Application 532. Hazards and Complications 533. Air-entrainment Nebulizer 534. Indications and Contraindications 535. Application 536. FIGURE 12-7 Various aerosol attachments. Left to right: Face tent, T-piece attached to an endotracheal tube, pediatric aerosol mask, infant aerosol mask, and tracheostomy mask (collar). 537. FIGURE 12-8 Blow-by method of oxygen administration used in postanesthesia recovery rooms. 538. Hazards and Complications 539. High-flow Nasal Cannula 540. Indications and Contraindications 541. Application 542. Hazards and Complications 543. Enclosures 544. Oxygen Tent 545. FIGURE 12-9 Oxygen mist tent. 546. Indications and Contraindications 547. Hazards and Complications 548. Oxygen Hood 549. Indications and Contraindications 550. Application 551. FIGURE 12-10 Infant oxygen hood with gas delivered through an oxygen blender system with heated humidification. The oxygen analyzer sensor is placed inside the hood close to the infant's head. 552. FIGURE 12-11 Tent house for oxygen administration to larger infants. 553. FIGURE 12-12 Older pediatric patient requiring low oxygen concentration after surgical repair of earlobes. Because use of a face mask or cannula would require straps or tubing placed around the patient's ears, a hood is used. 554. Hazards and Complications 555. Incubators 556. Indications and Contraindications 557. Application 558. Hazards and Complications 559. Manual Resuscitation Systems 560. Self-inflating Resuscitation System 561. FIGURE 12-13 Pediatric (top) and neonatal (bottom) self-inflating manual resuscitation bags. 562. Non–self-inflating Resuscitation System 563. FIGURE 12-14 Neonatal non–self-inflating manual resuscitation bag with in- line pressure manometer. 564. ASSESSMENT QUESTIONS 565. References
  • 22.
    566. Chapter 13Aerosols and Administration of Medication 567. LEARNING OBJECTIVES 568. NEONATAL AND PEDIATRIC MEDICATION DELIVERY 569. Box 13-1 Factors That Reduce Rate and Depth of Aerosol Particle Deposition in Neonatal and Pediatric Patients 570. FIGURE 13-1 Although the percentage of drug deposited in the lung varies with age (darker columns), the percentage of lung deposition corrected for body weight (lighter columns) is consistent across age groups. 571. FIGURE 13-2 Assessing nebulizer performance. F, frequency; I:E, ratio of inspiratory to expiratory time; IFR, inspiratory flow rate; VT, tidal volume. 572. AEROSOL ADMINISTRATION IN NONINTUBATED INFANTS AND CHILDREN 573. DEPOSITION IN INTUBATED INFANTS 574. FIGURE 13-3 A dose of 200 μg of albuterol was administered by jet nebulizer or metered dose inhaler (MDI) with chamber to infants with bronchopulmonary dysplasia, between 1 and 4 kg in size, and either ventilated or nonventilated. Mean (SEM) values for lung deposition are shown in A, nonventilated infants (n = 13) and B, ventilated infants (n = 10). Values are given as the percentage of the amount delivered to the infants and, for nebulizers, also as the percentage of the initial nebulizer dose. The absolute amount (μg) of salbutamol deposited in the lungs (solid columns) is given for reference. 575. AEROSOL CHARACTERISTICS 576. Deposition of Particles 577. Translocation of Aerosols 578. Drug Dose Distribution 579. AEROSOL DELIVERY 580. Pneumatic Nebulizers 581. FIGURE 13-4 Aerosol generated and inhaled during nebulization therapy. A, Continuous nebulization; B, breath-enhanced nebulization; C, breath-actuated nebulization. 582. FIGURE 13-5 Distribution of albuterol delivered via nebulizer (NEB), pressurized metered-dose inhaler (MDI), and pressurized metered-dose inhaler with holding chamber (MDI/HC). 583. Large-volume Nebulizer 584. Small-particle Aerosol Generator 585. FIGURE 13-6 Diagram of small-particle aerosol generator (SPAG), which may be used with a hood, tent, mask, or ventilator. psig, Pounds-force per square inch gauge. 586. Ultrasonic Nebulizers 587. FIGURE 13-7 Aerosol is produced in an ultrasonic nebulizer by focusing sound waves, which disrupt the surface of the fluid, creating a standing wave that produces droplets. Flow from a fan pushes the aerosol out of the chamber. 588. Vibrating Mesh Nebulizers 589. Pressurized Metered-dose Inhalers 590. FIGURE 13-8 Cross-sectional diagrams of a pressurized metered-dose inhaler. 591. Technique
  • 23.
    592. Box 13-2Optimal Self-administration Technique for Using Pressurized Metered-dose Inhaler 593. Accessory Devices 594. Flow-triggered Device 595. Spacers and Holding Chambers 596. FIGURE 13-9 Metered dose inhaler holding chambers are spacers with one- way valves that allow the chamber to be emptied only when the patient inhales, by preventing the exhaled gas from re-entering the chamber. 597. Box 13-3 Optimal Technique for Using Pressurized Metered-dose Inhaler With Valved Holding Chamber 598. Wheezing Infants 599. Care and Cleaning 600. Dry Powder Inhalers 601. FIGURE 13-10 As patient inhales through a dry powder inhaler, inspiratory flow deaggregates particles from the powder bed or capsule and is drawn through a screen that strips the small drug particles from the larger carrier particles, creating an aerosol dispersion. 602. FIGURE 13-11 Fine particle mass delivered from a 100-μg target dose (±SD) as a function of flow rate. pMDI, Pressurized metered-dose inhaler; BAMDI, breath- actuated MDI (Autohaler); DPI 1, Rotahaler; DPI 2, Turbuhaler; DPI 3, Diskhaler. 603. FIGURE 13-12 Peak inspiratory flows in individual inexperienced children and in groups of experienced children. 604. TABLE 13-1 Differences in Inhalation Technique Between Pressurized Metered-dose Inhaler With Holding Chamber and Dry Powder Inhaler 605. DEVICE SELECTION AND COMPLIANCE 606. TABLE 13-2 Comparison of Pressurized Metered-dose Inhaler With Holding Chamber, Dry Powder Inhaler, and Nebulizer as Aerosol Delivery Device 607. EMERGENCY BRONCHODILATOR RESUSCITATION 608. Intermittent versus Continuous Therapy 609. FIGURE 13-13 Rates of hospitalization of patients with asthma from the emergency department after treatment with albuterol (control) or with albuterol and ipratropium (ipratropium). Numbers in columns, number of children tested. In patients with moderate asthma, no difference was seen in hospitalization rate. In patients with severe asthma, the benefits of combined therapy were significant. 610. Undiluted Bronchodilator 611. MECHANICAL VENTILATION 612. Box 13-4 Variables That Affect Aerosol Delivery and Deposition During Mechanical Ventilation 613. VENTILATOR RELATED 614. DEVICE RELATED 615. Metered-dose Inhaler 616. Nebulizer 617. CIRCUIT RELATED 618. DRUG RELATED 619. PATIENT RELATED 620. Factors Affecting Aerosol Delivery
  • 24.
    621. Ventilator–Patient Interface 622.Breath Configuration 623. FIGURE 13-14 MDI holding chambers to use in-line with mechanical ventilator circuits or in intubated patients or those with tracheostomies. 624. Airway 625. Environment 626. Response Assessment 627. FIGURE 13-15 Measurements of respiratory system resistance (Rrs) before, and 15, 30, 60 and 120 min after, salbutamol treatment via a metered dose inhaler (MDI), a jet nebulizer (Jet: Sidestream), and an ultrasonic nebulizer (US). *Posttreatment values were significantly lower than the pretreatment Rrs, P < 0.0001. 628. Nebulizer Placement 629. Inhaler Adapters 630. Aerosol Particle Size 631. Endotracheal Tube 632. Heating and Humidification 633. Density of Inhaled Gas 634. Ventilator Mode and Settings 635. Technique of Aerosol Administration in Critical Care 636. BRONCHODILATOR ADMINISTRATION 637. Inhaler versus Nebulizer 638. Care of Accessory Devices and Nebulizers 639. Box 13-5 Technique for Using Nebulizers to Treat Mechanically Ventilated Patients 640. HOME CARE AND MONITORING COMPLIANCE 641. Box 13-6 Technique for Using Pressurized Metered-dose Inhalers to Treat Mechanically Ventilated Patients 642. OTHER MEDICATIONS FOR AEROSOL DELIVERY 643. Antibiotics 644. Mucoactive Agents 645. Surfactant 646. Hyperosmolar Aerosols 647. Gene Transfer Therapy 648. Aerosols for Systemic Administration 649. Insulin 650. SUMMARY 651. ASSESSMENT QUESTIONS 652. References 653. Chapter 14 Airway Clearance Techniques and Lung Volume Expansion 654. LEARNING OBJECTIVES 655. HISTORY AND CURRENT STATUS OF AIRWAY CLEARANCE TECHNIQUES 656. CHEST PHYSICAL THERAPY TECHNIQUES 657. Postural Drainage 658. Percussion 659. Postural Drainage and Percussion
  • 25.
    660. FIGURE 14-1Postural drainage positions for infants. A, Apical segment of the right upper lobe and apical subsegment of the apical–posterior segment of the left upper lobe. B, Posterior segment of the right upper lobe and posterior subsegment of the apical–posterior segment of the left upper lobe. C, Anterior segments of right and left upper lobes. D, Superior segments of both lower lobes. E, Posterior basal segments of both lower lobes. Postural drainage positions for infants. F, Lateral basal segment of the right lower lobe. Lateral basal segment of the left lower lobe is drained in a similar fashion but with the right side down. G, Anterior basal segment of the right lower lobe. The segments on the left side are drained in a similar fashion but with the right side down. H, Right middle lobe. I, Left lingular segment of lower lobe. 661. FIGURE 14-2 Postural drainage positions for the child or adult. The model of the tracheobronchial tree next to or above the child illustrates the segmental bronchi being drained. The stippled area on the child's chest illustrates the area to be percussed or vibrated. A, Apical segment of right upper lobe and apical subsegment of apical–posterior segment of left upper lobe (area between the clavicle and top of the scapula). B, Posterior segment of right upper lobe and posterior subsegment of apical–posterior segment of left upper lobe (area over the upper back). Postural drainage positions for the child or adult. The model of the tracheobronchial tree next to or above the child illustrates the segmental bronchi being drained. The stippled area on the child's chest illustrates the area to be percussed or vibrated. C, Anterior segments of right and left upper lobes (area between clavicle and nipple). D, Superior segments of both lower lobes (area over middle of back at tip of scapula, beside spine). E, Posterior basal segments of both lower lobes (area over lower rib cage, beside spine). F, Lateral basal segment of right lower lobe. Segment on left is drained in a similar fashion but with the right side down (area over middle portion of rib cage). G, Anterior basal segment of left lower lobe. Segment on right is drained in a similar fashion but with the left side down (area over lower ribs, below the armpit). H, Right middle lobe (area over right nipple; below breast in developing females). I, Left lingular segment of lower lobe (area over left nipple; below breast in developing females). 662. FIGURE 14-3 Proper cupping of hand for percussion. 663. FIGURE 14-4 Percussion being performed on a child with a manual percussor. 664. Vibration of the Chest Wall 665. CHEST PHYSICAL THERAPY IN THE NEWBORN 666. CHEST PHYSICAL THERAPY IN YOUNG CHILDREN 667. Adverse Consequences 668. Cough 669. Forced Expiration Technique 670. Coughing and Forced Expiration Technique 671. Positive Expiratory Pressure Therapy 672. Autogenic Drainage 673. Positive Expiratory Pressure Therapy and Autogenic Drainage 674. High-frequency Chest Compression 675. FIGURE 14-5 Graphic illustration of the depth of successive breaths by lung volumes, using the autogenic drainage technique. COPD, Chronic obstructive
  • 26.
    pulmonary disease; ERV,expiratory reserve volume; HUFF, huff maneuver; PRED, predicted; RV, residual volume; TV, tidal volume. 676. FIGURE 14-6 Patient wearing an inflatable vest during high-frequency chest compression therapy in the home. 677. Effectiveness of Techniques 678. COMPLICATIONS OF CHEST PHYSICAL THERAPY 679. Hypoxemia 680. Position 681. Percussion 682. Atelectasis 683. Bronchospasm 684. Increased Oxygen Consumption 685. Gastroesophageal Reflux 686. Airway Obstruction and Respiratory Arrest 687. Intracranial Complications 688. Rib Fractures and Bruising 689. Airway Trauma 690. SELECTION OF PATIENTS FOR CHEST PHYSICAL THERAPY 691. Conditions in Which Chest Physical Therapy May Not Be Beneficial 692. Conditions in Which Chest Physical Therapy May Be Beneficial 693. Acute Lobar Atelectasis 694. FIGURE 14-7 Algorithm for evaluating patients for chest physical therapy. 695. Cystic Fibrosis 696. Neuromuscular Disease or Injury 697. Lung Abscess 698. CONTRAINDICATIONS 699. LENGTH AND FREQUENCY OF THERAPY 700. THERAPY MODIFICATION 701. MONITORING DURING THERAPY 702. EVALUATION OF THERAPY 703. DOCUMENTATION OF THERAPY 704. INCENTIVE SPIROMETRY 705. Indications, Contraindications, and Complications 706. Box 14-1 Indications for Incentive Spirometry 707. Devices 708. Procedure 709. Application 710. FIGURE 14-8 Child using incentive spirometry device. 711. Assessment of Therapy 712. INTERMITTENT POSITIVE-PRESSURE BREATHING 713. Indications, Contraindications, and Complications 714. Equipment 715. Box 14-2 Complications Associated With Intermittent Positive-Pressure Breathing 716. Procedure 717. Application
  • 27.
    718. FIGURE 14-9Intermittent positive-pressure breathing (IPPB) therapy being administered to a child, with a respirometer attached to the exhalation valve for exhaled volume monitoring. 719. Monitoring 720. Assessment of Therapy 721. FUTURE OF AIRWAY CLEARANCE THERAPY 722. ASSESSMENT QUESTIONS 723. References 724. Chapter 15 Airway Management 725. LEARNING OBJECTIVES 726. INTUBATION 727. Indications 728. Equipment 729. Endotracheal Tubes 730. TABLE 15-1 Essential Equipment for Intubation 731. FIGURE 15-1 Endotracheal tube with distance markings. 732. TABLE 15-2 Neonatal Resuscitation Program Guidelines for Pediatric Endotracheal Tube Size 733. Cuffed and Uncuffed Tubes 734. Laryngoscope Blades and Handles 735. FIGURE 15-2 Direct laryngoscopy using a straight (Miller) blade. 736. Laryngeal Mask Airway 737. FIGURE 15-3 Direct laryngoscopy using a curved (MacIntosh) blade and demonstrating proper lifting technique. Note the upward and forward lift while the wrist is held straight. 738. FIGURE 15-4 A laryngeal mask airway (LMA). 739. Suction Equipment 740. TABLE 15-3 Suggested Laryngeal Mask Airway Size Based on Weight 741. INTUBATION PROCEDURE 742. Orotracheal Intubation 743. FIGURE 15-5 Glottic structures viewed through the laryngoscope. 744. FIGURE 15-6 Anterior–posterior chest radiograph of right main bronchus intubation of a toddler. 745. FIGURE 15-7 Anterior–posterior chest radiograph of properly positioned endotracheal tube. 746. Nasotracheal Intubation 747. FIGURE 15-8 Steps used to secure an endotracheal tube (ETT) with tape. Steps A and B, Slit two pieces of tape, making a Y on one end of each piece (as shown). Turn under the end of the tape that will be wrapped around the ETT. This will make tape removal easier. Step C, Apply benzoin to the area below the nose and across the cheeks (where tape will be placed). Attach one piece of tape to the cheek and below the nose, wrapping the bottom of the Y around the ETT. The tape should be placed under the tube (chin side) first, and then wrapped around the top of the tube. Step D, Repeat step C on the other side of the face. 748. Box 15-1 Equipment for Endotracheal Tube Stabilization
  • 28.
    749. FIGURE 15-9The NeoBar. A commercial adaptation of the Logan bow for stabilizing an infant endotracheal tube. 750. Blind Nasal Intubation 751. Oral versus Nasal Intubation 752. Neonatal Intubation 753. Approaches to the Difficult Airway 754. Anterior Commissure Intubation 755. FIGURE 15-10 Anatomic features of the normal larynx (A), and of the larynx in the presence of mandibular hypoplasia (B) In the presence of mandibular hypoplasia, the posterior displacement of the tongue makes the larynx appear more anteriorly situated than normal. 756. FIGURE 15-11 Laryngoscope placed laterally in the right oral commissure (A), permitting more complete visualization of the larynx than when the instrument is passed in the standard midline position (B). 757. Flexible Fiberoptic Intubation 758. Emergency Tracheotomy 759. FIGURE 15-12 Laryngoscopy and intubation. A, With laryngoscope in lateral position (A), approximately 30 degrees of anterior angulation is gained over the standard midline position (B), thus permitting more complete visualization of the larynx. B, Endotracheal tube (without 15-mm anesthetic adapter) is inserted into the barrel of the laryngoscope under direct visualization. In this example, an optical stylet is used. C, The endotracheal tube is grasped with alligator forceps and advanced slightly (small arrow) as the laryngoscope is withdrawn (large arrow). D, Anesthetic adapter (15 mm) is replaced, and ventilation is begun. 760. Epiglottitis 761. FIGURE 15-13 Lateral soft tissue neck radiograph revealing epiglottitis. 762. Laryngotracheal Stenosis 763. Artificial Airway Cuff Management 764. Patient Monitoring 765. Complications 766. EXTUBATION 767. Accidental Extubation 768. Equipment 769. Procedure 770. Explanation to Patient and Parent 771. Complications 772. Extubation Failure 773. Treatment Strategies 774. Nasal Mask Ventilation, Heliox 775. Laryngotracheal Reconstruction 776. TRACHEOTOMY 777. Tracheotomy Indications 778. Tracheotomy Tubes 779. TABLE 15-4 Age and Tracheotomy Tube Size* 780. TABLE 15-5 Dimensions of Three Commonly Used Brands of Tracheotomy Tube
  • 29.
    781. FIGURE 15-14Midsagittal section of a trachea with tracheotomy tube in position. This reveals two common problems: suprastomal granulation tissue (open arrow) and suprastomal collapse (solid arrow). 782. FIGURE 15-15 Diagram of a tracheostomy securing system with Velcro ties. 783. Procedure and Technique 784. FIGURE 15-16 An infant in a hyperextended position for tracheotomy. 785. Complications 786. FIGURE 15-17 Tracheotomy procedure with two stay sutures placed on either side of the tracheotomy incision. 787. Tracheotomy Tube Changes 788. FIGURE 15-18 Passy-Muir tracheostomy speaking valve enabled by redirecting exhaled air around the tracheostomy tube and through the larynx and upper airway. 789. Box 15-2 Equipment Needed for Tracheotomy Tube Changes 790. Tracheotomy Home Care 791. Decannulation 792. Box 15-3 Equipment Needed for Tracheotomy Tube Care 793. FIGURE 15-19 Repair of suprastomal collapse, using absorbable sutures placed on the collapsing suprastomal cartilage and tied to the stomal skin. 794. Decannulation Methods 795. Airway Reconstruction 796. Box 15-4 Evaluation for Decannulation 797. FIGURE 15-20 Proposed grading system for subglottic stenosis based on endotracheal tube size. ID, inner diameter; NO, no obstruction. 798. FIGURE 15-21 Laryngotracheoplasty using an anteriorly placed costal cartilage graft. 799. FIGURE 15-22 A posteriorly placed costal cartilage graft maintains excellent expansion of the cricoid and glottis. 800. FIGURE 15-23 Partial cricotracheal resection. Dissection of the stenotic trachea away from the esophagus. 801. SUCTIONING 802. Procedure 803. Nasotracheal Suction 804. Bulb Suction 805. Closed Tracheal Suction Systems 806. Assessment Questions 807. References 808. Chapter 16 Surfactant Replacement Therapy 809. LEARNING OBJECTIVES 810. THE DISCOVERY OF SURFACTANT 811. FIGURE 16-1 A, Pressure–volume relationship of air-filled versus liquid-filled lung from von Neergaard's original data (1929). B, The difference in recoil attributed to a liquid–air interface (i.e., “bubble lining”) that is eliminated by a liquid-only interface. P, Pressure; tiss, tissue; int, air–liquid interface; liq, liquid. 812. SURFACTANT PHYSIOLOGY 813. Function
  • 30.
    814. FIGURE 16-2A, Alveolar surface tension is a manifestation of the strong attraction between molecules that are aligned on the surface of the alveoli. B, During expiration, when the alveolar radius is smaller, attraction between the molecules is stronger and there is a greater tendency to collapse. C, When surfactant is present, it spreads over the alveolus and dilutes the molecules. D, During expiration, the surfactant is compressed and the alveolar surface tension is lowered. This stabilizes the alveoli and prevents collapse of those with smaller radii. 815. Box 16-1 Surfactant Function 816. Surfactant Metabolism and Composition 817. FIGURE 16-3 A, Type II cell from a human lung, showing characteristic lamellar inclusion bodies (open arrows) within the cell, which are the storage sites of intracellular surfactant. Microvilli (solid arrows) are projecting into the alveolus (Alv). B, Beginning exocytosis of a lamellar body into the alveolar space of a human lung. C, Secreted lamellar body and newly formed tubular myelin (appearing as a lattice) in the alveolar liquid in a fetal rat lung. Membrane continuities between outer lamellar bodies and adjacent tubular myelin provide evidence of intraalveolar tubular myelin formation. 818. FIGURE 16-4 Schematic diagram of surfactant metabolism. 1, secretion of LB; 2, conversion of LB into TM; 3, generation of monolayer from TM material; 4, formation of small aggregate material from monolayer; 5, reuptake of surfactant material. In general, solid arrows indicate accepted pathways. Probable pathways are indicated by dashed arrows. N, nucleus; ER, endoplasmic reticulum; CB, composite body; LB, lamellar body; TM, tubular myelin. 819. TABLE 16-1 Components of Pulmonary Surfactant 820. FIGURE 16-5 A cross-section of an alveolus wall is shown. In the presence of surfactant protein B (not shown), dipalmitoylphosphatidylcholine (DPPC) aligns in the air–liquid interface with the hydrophobic end toward the gas phase (air space) and hydrophilic end toward the liquid phase (liquid surface). Strong molecular interactions occur between the polar heads of the hydrophobic end. Note that the polar head has a positive charge associated with its nitrogenous base (N) and a negative charge associated with its phosphate group (P). This alignment creates electrostatic forces of repulsion, pushing water molecules apart, preventing atelectasis, and holding the airway open during exhalation. 821. Hormonal Effects on Surfactant Production 822. Fetal Lung Maturity Testing 823. TABLE 16-2 Fetal Lung Maturity Testing* 824. SURFACTANT DYSFUNCTION IN ACUTE LUNG INJURY 825. Altered Surfactant Quantity 826. Altered Surfactant Composition 827. Box 16-2 Diseases That Affect Surfactant 828. Altered Surfactant Metabolism 829. Surfactant Inactivation 830. CLINICAL APPLICATIONS AND REPLACEMENT 831. Respiratory Distress Syndrome 832. Incidence 833. Treatment
  • 31.
    834. FIGURE 16-6Four pathways that contribute to surfactant dysfunction during acute lung injury. FRC, functional residual capacity; SP-A, surfactant protein A. 835. TABLE 16-3 Clinical Presentation of Surfactant Deficiency RDS and ARDS 836. FIGURE 16-7 A, Chest radiograph of a premature infant with respiratory distress syndrome (RDS) demonstrating diffuse reticulogranular pattern (ground- glass appearance), air bronchograms, and low lung volume. B, Chest radiograph of the same premature infant after surfactant administration, demonstrating improved lung volumes. C, Photomicrograph of normal alveoli, demonstrating normal microscopic structure of the lung of a newborn infant. Clear areas are the air- containing expanded alveoli. The colored structures that form a honeycomb lattice are the walls that line the alveolar space. D, Microscopic structure of the lung from a premature infant who died of RDS. The normal honeycomb lattice is collapsed (atelectasis), the alveolar walls are adherent to each other, and the lung is almost airless. Those air-containing spaces (clear areas) that do remain are lined by a pink- staining layer of inflammatory protein termed the hyaline membrane. 837. Prophylaxis 838. Rescue and Multiple Treatments 839. Natural versus Synthetic Preparations 840. TABLE 16-4 Surfactant Delivery 841. Nonresponders 842. TABLE 16-5 Types of Surfactant 843. Pulmonary Hemorrhage 844. Meconium Aspiration Syndrome 845. Pneumonia and Sepsis 846. Congenital Diaphragmatic Hernia 847. Extracorporeal Membrane Oxygenation 848. Acute Respiratory Distress Syndrome 849. FIGURE 16-8 Changes in oxygenation after surfactant administration. Circles, surfactant group; diamonds, placebo group. 850. Viral Bronchiolitis 851. Asthma 852. Cystic Fibrosis 853. FUTURE DIRECTIONS 854. CASE STUDIES 855. CASE 1 856. CASE 2 857. ASSESSMENT QUESTIONS 858. References 859. Chapter 17 Mechanical Ventilators 860. LEARNING OBJECTIVES 861. VENTILATOR CLASSIFICATION 862. Input Power 863. Power Conversion and Transmission 864. Control 865. Control Circuit 866. Control Variables and Waveforms
  • 32.
    867. FIGURE 17-1A paradigm for understanding mechanical ventilators based on the equation of motion for the respiratory system. The model illustrates that during inspiration the ventilator can control only one variable at a time. The diagram shows common waveforms for each control variable. Pressure, volume, flow, and time are also used as phase variables that determine the characteristics of each ventilatory cycle. The diagram is drawn as a flow chart to emphasize that each breath may have a different set of control and phase variables, depending on the mode of ventilation used. 868. Pressure 869. Volume 870. Flow 871. Time 872. Dual Control of the Inspiratory Phase 873. FIGURE 17-2 Criteria for determining the control variable during a ventilator- assisted inspiration. 874. Phase Variables 875. Trigger 876. Limit 877. FIGURE 17-3 Criteria for determining the phase variables during a ventilator- assisted breath. 878. Cycle 879. Baseline 880. Modes of Ventilation 881. Conditional Variables 882. Spontaneous versus Mandatory Breaths 883. Output 884. Alarm Systems 885. Input Power Alarms 886. Control Circuit Alarms 887. Output Alarms 888. NEONATAL/INFANT CRITICAL CARE VENTILATORS 889. Bear Medical Systems Bear Cub 750vs 890. Dräger Medical Babylog 8000 plus 891. Power Conversion and Transmission 892. FIGURE 17-4 Babylog 8000 plus infant ventilator (Dräger Medical). 893. Control 894. Output 895. Waveforms 896. Monitoring 897. TABLE 17-1 Control and Phase Variables for Mandatory and Spontaneous Breaths in the Operational Modes Available With the Dräger Medical Babylog 8000 plus Infant Ventilator 898. Alarms 899. Input Power Alarms 900. Control Circuit Alarm 901. Output Alarms
  • 33.
    902. Puritan BennettInfant Star 500 903. Sechrist IV-200 With SAVI System 904. Power Conversion and Transmission 905. FIGURE 17-5 Sechrist IV-200 infant ventilator (Sechrist Industries). 906. Control 907. Output 908. Waveforms 909. Monitoring 910. TABLE 17-2 Control and Phase Variables for Mandatory and Spontaneous Breaths in the Operational Modes Available With the Sechrist IV-200 Ventilator With SAVI System 911. Alarms 912. Input Power Alarms 913. Control Circuit Alarms 914. Output Alarms 915. UNIVERSAL NEONATAL/INFANT/PEDIATRIC/ADULT CRITICAL CARE VENTILATORS 916. V.I.P. Bird 917. Cardinal Health AVEA 918. Power Conversion and Transmission 919. Control 920. FIGURE 17-6 AVEA ventilator (Cardinal Health). 921. Output 922. Waveforms 923. Monitoring 924. Alarms 925. Input Power Alarms 926. Control Circuit Alarms 927. Dräger Medical Evita 4 and EvitaXL 928. Power Conversion and Transmission 929. FIGURE 17-7 Evita 4 ventilator (Dräger Medical). 930. Control 931. Output 932. Waveforms 933. Monitoring 934. TABLE 17-3 Control and Phase Variables for Mandatory and Spontaneous Breaths in the Operational Modes Available on the Dräger Medical Evita 4 Ventilator 935. Alarms 936. Input Power Alarms 937. Control Circuit Alarms 938. Output Alarms 939. Puritan Bennett 840 940. FIGURE 17-8 Puritan Bennett 840 ventilator (Covidien). 941. Power Conversion and Transmission 942. Control 943. Output
  • 34.
    944. Waveforms 945. Monitoring 946.Alarms 947. Input Power Alarms 948. TABLE 17-4 Control and Phase Variables for Mandatory and Spontaneous Breaths in the Operational Modes Available on the Puritan Bennett 840 Ventilator 949. Control Circuit Alarms 950. Output Alarms 951. Newport Wave VM200 952. Maquet Servo 300A 953. Maquet SERVO-i 954. Power Conversion and Transmission 955. FIGURE 17-9 SERVO-i ventilator (Maquet). 956. Control 957. Output 958. Waveforms 959. Monitoring 960. Alarms 961. Input Power Alarms 962. TABLE 17-5 Control and Phase Variables for Mandatory and Spontaneous Breaths in the Additional Available Modes on the Maquet SERVO-i Ventilator 963. Hamilton Medical Hamilton-G5 964. Power Conversion and Transmission 965. Control 966. FIGURE 17-10 Hamilton-G5 ventilator (Hamilton Medical). 967. Output 968. Waveforms 969. Monitoring 970. Alarms 971. Input Power Alarms 972. GE Healthcare Engström Carestation 973. Power Conversion and Transmission 974. Control 975. TABLE 17-6 Control and Phase Variables for Mandatory and Spontaneous Breaths in the Additional Available Modes on the Hamilton-G5 Ventilator 976. FIGURE 17-11 Engström Carestation ventilator (GE Healthcare). 977. Output 978. Waveforms 979. Monitoring 980. Alarms 981. Input Power Alarms 982. HOME CARE VENTILATORS 983. Puritan Bennett LP10 984. TABLE 17-7 Control and Phase Variables for Mandatory and Spontaneous Breaths in the Additional Available Modes on the Engström Carestation Ventilator 985. Puritan Bennett Companion 2801
  • 35.
    Random documents withunrelated content Scribd suggests to you:
  • 36.
    side, one beingbeyond the staircase. Her companion passed through that door to the left, and she followed him. They came upon a corridor, and stopped before the last door on the left-hand side. Her guide knocked, then opened it. There was no name to give; Rosalie had no tongue to speak, no card to show. Then the door closed again, and she found herself in the presence of the man whom she had come to seek. He was sitting by a table reading. A fire was burning in the hearth near by. A high shaded lamp stood on the ground beside him. The floor was thickly carpeted, the walls were lined with books from floor to ceiling, one other door led from the room. The Master looked up as she entered, then got up, pushing the book away. “So you have come,” he said. He came forward and held out his hand. Rosalie, trembling and uncertain, returned the hand-shake, nodding. “What! you cannot speak yet?” She shook her head, but as he was withdrawing his hand she clutched it eagerly, unconscious of anything but this one little sinking straw of hope. This time he looked at her more closely. “What is it?” he asked. She raised her other hand to her throat and mouth, then pointed to him, her eyes full on his face. “I’m not the Serpent,” he answered, and he shook his head and tried to disengage his hand. But Rosalie’s fingers tightened with a fierceness and determination altogether foreign to her. Her cheeks flushed, her eyes flashed angrily; she gave one little imperious stamp with her foot. The Master looked at her and smiled—a smile that travelled from his eyes to the corners of his mouth. “I see. You do not intend to go till I have performed an—an impossibility?” Rosalie nodded in all seriousness. “It is the gift of speech you’re wanting?”
  • 37.
    She nodded. “It’s verydangerous; leads people into all kinds of indiscretions.” She shook her head vehemently. “You think you differ from the commonality?” But Rosalie neither shook her head nor nodded. She only looked up at him with no other expression in her eyes except dumb entreaty. “Come to the light,” said he, “and try to look less ghostly. After all, if you can’t be cured you can’t. You’re brave enough to stand that, aren’t you?” Again she nodded, still looking at him. He pushed the shade of the lamp up. “Now open your mouth,” he said. Obediently Rosalie did as she was told. “Why, you’ve got a tongue!” said he, bending his brows, and stooping down to her. “Can’t you move it?” But Rosalie could not. It was complete paralysis of the muscles evidently. “Come with me, and I’ll see what I can do.” He led her through the other door into another room. The walls of this place were lined with chests and cupboards with glass fronts, containing curious instruments. In the centre was a long table. The room was also fitted up with chairs such as dentists use, and a marble washing basin fitted with water pipes, hot and cold. Yet when the light was turned on the general effect was cheerful. Rosalie found it so, at any rate, for renewed hope was springing in her heart. She sat down upon the chair he drew for her, and watched him whilst he went to the cupboard and brought out something shaped like a very long darning needle. It was thick at one end, very fine and pointed at the other. Then from another shelf containing flasks of glass polished and cut he took a liquid shining like silver, and poured some into a tiny crucible. With these he came back to her and placed them on the table. Then he looked at her, smiling. “This will hurt you very much,” he said; “but you asked for it, so you will have to go through with it.”
  • 38.
    Anyone but Rosaliewould have noticed that the expression of his face was not particularly kind. But she noticed nothing. She leant back against the head-rest; he placed his hand upon her eyes. After that they were too heavy for her to open them. She opened her mouth instead. It was a curious kind of pain, if pain it could be called. Never in the whole of her life had she ever felt anything so soothing. She could not tell how long the sensation lasted, but it ceased very suddenly. Then although her eyes were closed she felt (this was the curious part of it) a strong light shining into her mouth, right back to the roots of that so far silent tongue. It was a light that had the power to heal and strengthen, and for a long, long time it played upon every unused nerve and delicate muscle. At last all was over; the master laid his hand upon her eyes again and opened them. “Now,” said he, “the miracle has been performed. Are you satisfied?” From long custom Rosalie nodded. “You must speak,” he answered, laughing, “if but to show your appreciation of the gift.” “Thank you,” she said, quite perfectly, with just a little break in the word that took nothing from its sweetness. “Did you find the pain very bad?” “I nev-er felt it.” “Never felt it?” he repeated. “Give me your hand.” But her pulse was even, and he frowned. “Where did you come from when you came to me?” he asked, bending his eyes down to hers with a keen, penetrating glance. “I came from the temple.” “From the prayer?” “Yes.” “Then you—” but here he stopped. “I see,” he continued, but in reality he didn’t. “Did you expect I should be hurt?” she asked. “I can hardly believe you were not.” “But I should have screamed. I made no sound.”
  • 39.
    “That was scarcelypossible. For my own part, I always think it best to guard against screams, they are so unhelpful and unnecessary.” Now Rosalie looked at him, with eyes just as keen and penetrating as his had been. “Why do you stare at me?” he asked, smiling. “To see if you are disappointed.” Here he laughed. “Be careful. Your tongue is getting rather out of bounds already.” “I think you would rather have enjoyed my being hurt.” “Well, what can you expect in a country where vivisection is disallowed? One must take what little pleasure one can get.” Here he led the way back into the outer room. When they were both through he turned the key and put it in his pocket. “I rarely go in there,” he said. “Few folks are fool enough to come to me. I have no ambition to become a doctor, and I shun the popularity that hangs upon the quack.” They were both standing by the table now, one on either side. Rosalie’s eyes were fixed dreamily on a large glass ink-stand in the centre of the table. She was beginning to feel indescribably tired. There was nothing very wonderful in this, the operation had lasted longer than she was aware. But though tired, she was feeling remarkably light-hearted, longing to get outside and give herself two or three decided pinches to become convinced she was awake, and that this great good fortune of her prayer had at last come to her. But over and above the tired feeling and the unreality came gratitude to her deliverer. The thought of this made her suddenly raise her eyes and look across at him. Certainly his face was very proud, and the shadows lurking underneath his eyes and at the corners of his mouth gave it a dark, forbidding expression. It was not altogether pleasant. “The feature I like best is his nose,” thought Rosalie. “The one that frightens me most is his mouth; the one that most interests me is his eyes.” “You have been very kind to me,” she said. “Is there any way in which I can pay you back?”
  • 40.
    But he shookhis head. “I do not think you could give me anything tangible, but perhaps you yourself will be able to suggest something.” Rosalie flushed to the roots of her hair. “I haven’t anything,” she answered. “Not even a soul?” “What is that?” “That part of you which under certain conditions becomes immortal.” “That part of me belongs to the Serpent.” “The Serpent passed you on body and soul to me.” “The Serpent did nothing of the sort,” she answered vehemently, if slowly. “I—I—I—” “You what?” “I nothing.” His eyebrows came together in a frown. “Yes,” he answered quietly, “there is one way in which you can pay me back. Speak the truth in answering my questions.” “I’ll try,” said Rosalie meekly. “Then put an ending to that ‘I—I—I—.’” “I came because I thought it was time. I got a little bit tired of the Serpent.” “Why?” “Because it never took any notice of me.” “Are you sure?” Rosalie’s curious eyes looked up innocently and met his. “Does that surprise you very much?” “I confess that it does.” “Do you know, I’m very tired. If you don’t mind, I’ll come again to- morrow and talk it over.” But he shook his head, and smiled again. “I don’t think I’ll let you go,” he said. “Your answers are not very satisfactory. Besides, where is there you can go?”
  • 41.
    “Oh, with atongue one can go anywhere and do anything.” “You think so?” “Yes.” And here from sheer weariness and exhaustion she slipped down in the arm-chair beside her. It had been a very hard day, and the ending had told upon her strength. She had not fainted, however, she was only sleeping. Mr. Barringcourt crossed the room and looked at her very narrowly, even dropping on one knee to examine her features more nearly. It was a very pale, thin, and tired face he looked at, delicate and fragile, with dark lashes, and faint blue shadows underneath the closed eyes. The backs of her hands were rough, and he took each up and examined it as though he had been a fortune-teller—back and front. Then he began walking slowly back and forwards through the room. His face, though handsome after a kind, was certainly not of the most prepossessing; and yet in repose his expression was one of weariness and contempt. “What shall I do with her?” he muttered. “Keep her to prevent blabbing as usual. Keep her and bring her up to talk properly. When she is old enough, or rather fit enough, I’ll let her out on a lease long enough to take her to the devil. Always the same! everlastingly the same! coming and going, with nothing to give and everything to ask. Dull to the very core, chattering like magpies, smiling and aping God knows what! Rich and poor, all of them alike. And for some reason best known to myself I stand it. What an excellent patient fisherman I should make!” Then he sat down again very deliberately in his chair, and drew the book he had been reading towards him, at the same ringing a bell. The same man who had admitted Rosalie answered it. “Take her away, and see she doesn’t get out,” said he, without looking up; and the other evidently understood so well that he never asked a question.
  • 42.
    CHAPTER VI NEW EXPERIENCES WhenRosalie awoke next morning, it was with a pardonable sense of bewilderment and estrangement. Instead of the little bedroom, bare of carpet, and devoid of all furniture, except the poorest and the simplest, she found herself in one that was really palatial. The bed had deep hangings of red silk, and she was not up to date enough to tear them down as breeding microbes and all things unhealthy. Then by degrees, her eyes travelling beyond the bed, she gradually became acquainted with the other things within the room, washstand, dressing-table, sofa, chairs; and here Rosalie gave a squeal of delight, and jumped out of bed, for there opposite was a wardrobe, as respectable as carved black oak could make it. But it was not the wardrobe that attracted her attention so much as the mirror set full length in its middle door—a mirror larger than she had ever seen before or dreamt about. Rosalie was not vain, but she had always entertained a great longing to see her feet at the same time as her head, and had thought it only a luxury and privilege accorded to the rich. When she had become accustomed to this novel vision she walked over towards the windows. Here, so far as beauty was concerned, a disappointment waited on her. All three of them looked upon a high blank wall opposite. It gave a sense of extreme dulness to the place. Just then her explorations and discoveries were cut short by a knock at the door, and on it entered a woman carrying a tray holding a cup of tea. Rosalie, who understood nothing of this sort of thing, stared at it and the bearer.
  • 43.
    “I’m quite betternow, thank you,” she said, shaking her head. “I was a little tired last night. I’d rather not have my breakfast in bed, if you don’t mind.” “This is not your breakfast,” said the other, in a voice so well modulated that many seemingly more exalted might have envied it. “Oh, what is it?” said Rosalie, standing still with her hands behind her looking at it. “A cup of tea to help you to dress.” She had the sweetest voice imaginable. Rosalie thought it the saddest she had ever heard. “I shan’t be ten minutes dressing,” she replied decidedly. “Quite an hour, I should say,” replied the other. “Oh!” gasped Rosalie. Then she clapped her hands together, caught up the flowing robe and skipped across the room to the bed. “If I’m not dressed in ten minutes, my name’s not Rosalie Paleaf.” Then with a sudden change to alarm in her manner, she turned round, growing alternately hot and cold. “I say, where are my things? I can’t see them anywhere.” “I took them away last night. There are your clothes for the day.” And she directed her attention to a chair on which some very pretty and expensive lingerie was laid. Rosalie looked at it, then drew herself up. “I want my own clothes,” she said. “These are too good for me; the others might be poor, but they were my own.” “I am afraid you cannot have them; you must dress in these.” The tears rose in Rosalie’s eyes. “I want my own clothes,” she said again. “Auntie and I cut and made them together. They were the last pair of stockings that she ever knit.” There was no answer. “Won’t you bring them back?” said Rosalie at last, the tears still standing in her eyes. “I am afraid it is against the rules of the house.”
  • 44.
    Then Rosalie gotup with a sigh, and prepared to get inside the first garment. “There is your bath first.” “I never bath in the morning; I always leave that till night.” “I think you had better do that which is customary.” Again Rosalie sighed, and followed her tormentress to an adjoining bath-room. And so it took her well on into the hour before she was dressed, ready to leave the bedroom. Mariana, who stayed to help her, insisted on arranging her hair, and after all arranged it much more becomingly than Rosalie herself had ever done. But the black robe with its red silk facings, that fitted her companion so becomingly, suited her not at all. The fit was as perfect as it could be, but otherwise she looked quite out of place in it. Breakfast was served on the same floor as that on which her bedroom was—three rooms away. All this portion of the house evidently looked out on to nothing better than the wall mentioned before; but the beauty of the interior compensated for outside gloom. Rosalie was charmed with everything she saw, though somewhat awe-struck, and she took her breakfast shyly from the hands of what she described to herself as the handsomest man she had ever seen. She also made a mental note that he must be brother to the man she saw downstairs. Rosalie had not gone all this time without grateful remembrance of that ordinary gift she had come to possess; but somehow there was some vague, indescribable thing in her surroundings that took away a full appreciation. She was longing to be outside, to talk with people more like herself, not all in black with red silk facings and knee breeches, and voices modulated to a soft perfection. Rosalie’s voice was sweet, but it was not the sweetness found in theirs. Hers was the outcome of expression, theirs of classical harmony. But how was she to get away? She dare not ask Mariana, for she was getting an uncomfortable idea that Mariana, from no ill motive, always thwarted and opposed her. So, watching her opportunity, she escaped and passed down the spiral staircase.
  • 45.
    In the bighall below all was silent as death. Evidently no one was about. She ran across to the big doors with a palpitating heart—outside them was freedom, she scarcely knew from what. Alas! Another hand had touched the large glass handle before her own. “Your card, madam. Your passport out.” “I have none. I shall not be away five minutes.” “I am afraid you cannot go.” “But I must go.” There was no answer. Exasperated, Rosalie stood and faced him. “You let me in, and you can let me out.” “The orders are that you are not to pass.” “Whose orders?” “The master’s.” “Then take me to him.” “He is engaged at present.” “I’ll go myself, then.”
  • 46.
    CHAPTER VII A DEBTOF GRATITUDE As Rosalie passed along the corridor her sudden decision was sealed by growing annoyance and a longing, almost amounting to fear, to get away. With scarcely a pause she knocked upon the door, that door through which she entered last night. Without stopping she opened it. Mr. Barringcourt was there alone, at a table littered with papers, writing. He was indeed busy and engrossed, for on her entrance he did not raise his head, till accosted by her voice, and then he looked up sharply enough. “You!” said he, bringing his eyebrows together in that dark frown which Rosalie had seen last night, and seeing had never forgotten. “Yes. I want to go out.” “Impossible!” said he, with an impatient gesture of his hand, and returned to the paper. “I want to go out,” she repeated. “And you have no right to stop me.” “In my own house I have every right. Go away, you are interrupting me.” “So are you interrupting me.” He laughed, not altogether kindly, and looked up at her again. “That is little short of impudent.” “I don’t care. I want to go out, and if you won’t give me leave, I shall take it.” “Take it then, by all means.” “That man at the door won’t let me.”
  • 47.
    “Knock him down.It will be one way of surmounting the difficulty.” “He is such an elephant. I disliked him the very first time I saw him,” she replied with energy, and as much simplicity as the truth occasioned. “Well, go away and fight it out with him; watch the door, and bounce out when he’s not looking.” “I won’t do anything so undignified. I shall make friends with the kitchen people, and creep out that way.” “The kitchen door leads into the garden, and the walls are high, and the gate is locked. I keep the key myself, to ensure no one getting to the stables.” “Then give me leave to go out at the front.” “Now, why should you want to go out at the front? You have as beautiful a home as you could possibly wish for. What more can you want?” “Fresh air and human beings.” “You have them here.” She shook her head. The tears rose in her throat, and were very hard to choke down again. “It’s the dismallest place I ever came to; and I’m no use. The people here always contradict me.” “You are the first person who has ever complained of them; and your opinion goes for nothing, your own conduct leaves so much to be desired.” “In what way?” “In my time I have experienced much ingratitude, but never any quite to equal yours.” “I—ungrateful?” “Most decidedly!” “What are you wanting from me?” “Quiet submission.” Rosalie’s eyes opened wide, her lips parted; her expression was one of unfeigned surprise.
  • 48.
    “What’s that?” “To dowhat you’re told quietly. Now you know, there is no excuse for your not complying.” “But to submit means to stay here.” “Of course!” “But I can’t. Oh, I can’t really! Anything but that.” “Nothing but that. You come to me with the most unusual request, and I am fool enough to put myself out of the way for you. Then you expect to go away, or rather slip away, without any more words about repayment. And when you are brought back, all this squalling.” “Nice people are quite content with ‘Thank you.’” “I’m not nice, and ‘Thank you’ never appeals to me.” “But if I stay here I can do nothing.” “Yes, you can mope.” “In return for a tongue?” “Why not? It would be the height of self-sacrifice, and the perfection of thanksgiving.” Her serious eyes met his thoughtfully. “Do you really wish me to stay here?” “I not only wish, but am determined on it.” “Then my self-sacrifice can never be spontaneous.” “You mean you are changing your mind. You are wishful to stop?” “Not wishful, but if you want it, I’ll—I’ll try to settle down more cheerfully. After all, it’s only just.” “That is so.” “Shall I often see you?” “Never. I am not fond of inflictions.” He spoke so drily, and the words were so unkind, that Rosalie’s wistful face grew paler. Yet still she argued to herself it would be selfish to wish to be free, to have a tongue and everything. And after all, the stranger was so clever that he must of necessity know best. “Will you let me out just for an hour?” she asked at length, with a voice greatly subdued from the first clamorous outburst. “Not for an hour.”
  • 49.
    “But I havean aunt, and she is dead. I shouldn’t like strangers to take what once belonged to her.” “Where is your uncle?” “He is dead too.” “Your people?” “I have none.” “Where then, in the name of all the devils in Lucifram, do you intend to go to?” “I thought when people knew I had miraculously come by a tongue they would—” “Ah! I thought as much. You want to behave with all the absurdity of a hen that has laid an egg.” “Indeed!” said Rosalie, flushing. “You want to get out just to cackle.” She was silent. “You admit it?” “I admit nothing but your want of manners.” “What a waspish, vinegarish tongue yours is.” “It’s the fault of the doctor, then. If one cannot produce a sweet instrument one might as well admit oneself a failure.” “How was I to tell? Your face was so deceptive.” “Maybe so is my tongue. I was only speaking in fun. Let me out for one hour. Lend me twopence, and I will return, having spoken to no one, and in the right frame for being submissive.” For a short time he was silent. At last he said: “Promise me faithfully you will return.” “I promise you most faithfully.” “Within the hour?” “Yes.” “You understand perfectly that my reason for bringing you back is not for any personal gratification I should derive from it. It is simply so that you may not obtain any great or particular pleasure from having a prayer perfected.” “You speak plainly enough for the dullest mind.”
  • 50.
    “I’m glad. Nowyou may go. And remember, come back if you have any sense of gratitude.” So Rosalie passed out again into the farther hall. “I have permission to pass,” said she at the door, and then she stood outside. It seemed to her when she reached the parapet that she had been out of the world for years. And oh! to be back in the world again! To see and hear the sights and sounds, so commonplace and ordinary, yet to her stilled ear so sweet again. Never had that terrible silent mansion struck her as so terrible till now she stood amongst the noise of work and life once more. One hour of freedom. One hour with the light, jogging world, and then to pass once more beneath the shadow—a silent spirit in a silent world. The ’bus rattled on, taking its own slow time towards that quarter of the city where she had lived. She found the upper storey empty, and none had missed her. Yesterday the doctor had told her his intention of coming for her at four o’clock to-day. It was not yet quite twelve. Each of the little rooms was now quite bare, except the tiny attic called her bedroom. In it were gathered the few trivial things she prized as belonging to days that were less dark than these. There was a necklace of coral, a collar of lace, a pair of gloves, kid, backed with astrachan, the last present her uncle ever gave her; a tiny brooch of gold, left by her aunt, and always worn by her, and but little else. One other thing she found, a book that in that planet compares nearly to our Bible. Sadly and lovingly she placed them all together, and kissed them many times, her eyes blinded with tears; and then a voice whispered: “Why go back? Go to this doctor. Tell him everything, for he is kind. None would blame you for not returning to that prison mansion, even though under a promise. It was an unfair advantage.” But Rosalie shook her head. “I must go back, because I promised. I asked everything in return for nothing. And God, in His own good time, will make the dark path plain.” The struggle gradually died, and Right conquered.
  • 51.
    At last shewas ready to go. Glancing round for the last time, she saw upon the mantelpiece a key, a solitary one upon an iron ring. “It belonged to uncle’s safe, the one that had so little in it,” she thought. She took it up. Its dull appearance suggested so much dull tragedy to her. “I’ll take it with me,” she thought, and slipped it in the pocket of her dress. Then she passed down the broad stone steps out once more into the street. Her brief holiday was over. The short hour was almost passed. She clenched her hands together, and drove back the blinding tears that struggled in her eyes. Gradually she drew nearer to the Avenue—how eagerly she had rushed there on the night before! The great black marble mansion came in view, its dusky grandeur having a certain sinister lowering to her understanding eye no different from a prison. “I wonder when I’ll walk along this street again?” she thought, and ascended the marble steps, hiding all trace of past emotion.
  • 52.
    CHAPTER VIII A BOOKOF INSPIRATION “The master wished to speak to you when you returned,” the attendant at the door said to her when he answered it. Rosalie crossed the hall, feeling that vague sense of satisfaction that generally accompanies honesty, and which at times appears so poor a recompense. This time on knocking she waited for the answer. When it came she opened the door and entered. Mr. Barringcourt was in the act of filing papers, and generally tidying up the littered table. “You are quite punctual,” said he. “And what is more, astoundingly honest.” “You did not expect I should return, then?” “No! Honestly speaking, I thought I had seen the last of you.” She shook her head. “Gratitude brought me back at the expense of inclination.” “You should have yielded to temptation, and run away.” “Perhaps my action in returning was not quite so commendable as you think. I was much tempted to run away, and then—” “What?” “I could find no place to go to.” “You have no appreciative friends?” “Not one.” “The doctor?” Rosalie looked up quickly, and flushed. “Why do you speak of him?”
  • 53.
    “I’m sure Idon’t know,” he answered drily; “I believe I was meaning myself.” “Oh—yes—of course,” stammered Rosalie. “I thought you meant Dr. Kaye.” “Then you had notions of appealing to him?” Rosalie laughed. “You are not the pleasantest of companions.” “You might as well make a confidant of me. I am the only one you will find for some time.” “Well, yes, then,” she answered, looking across at him with a timid glance. “I thought of running to the doctor, informing him you intended making a prisoner of me in a free city, and asking him to give me the benefit of his protection and advice.” “And you thought better of it?” “You told me if I was grateful I should return. I was grateful, and though there seems something very topsy-turvy about the recompense you ask for, there is something in it that appeals to my sense of justice.” “That is why you came back?” “There is no other reason.” Mr. Barringcourt all this time had been sitting in his chair by the table. Rosalie was standing at the farther side of it. Now he got up and walked over to the fireplace, where the fire was burning brightly. “What is your name?” he asked. “Rosalie Paleaf.” “Brought up by an aunt and uncle?” “Yes.” “Always dumb, and therefore very much out of the world?” “Yes.” “Where did you learn the little bit of knowledge you possess?” “I listened to it. I was not deaf, you know.” “Could you read?” “Yes, I can read. That is how I used to spend most of my time.” “Travels, novels, or biography?”
  • 54.
    “A little bitof both—all three, I mean. ‘The Life of Krimjo on the Desert Island,’ which was my favourite, contained a little of all, I think.” “Ally Krimjo was only make-belief,” said he ruthlessly. “Indeed he wasn’t! He had gone through everything he spoke about, the shipwreck and the loneliness, the savages and everything. Make-belief! Oh, Mr. Barringcourt, have you ever really read it through?” “Yes, at the time it was written.” Here Rosalie laughed again triumphantly. “That shows you don’t know the book I’m talking about at all. The man who wrote it lived hundreds of years ago. Quite three hundred, I should say.” “At that rate I must be mistaken. Then if you are so fond of travel and biography, I have some volumes here all on that subject, written, too, about the time you speak of. You will have a great deal of time lie heavy on your hands; perhaps you would like some?” Rosalie looked dubious, and her eyes travelled to the imposing- looking book-shelves. “I never found anyone quite to come up to Ally Krimjo,” she replied regretfully. “You refuse my offer?” “Not if you give me something interesting. But as a rule I don’t like biographies, because the people always die. Now, Ally Krimjo—” “You’re quite right,” said Mr. Barringcourt grimly. “Ally Krimjo hasn’t died, so he deserves to live. Have you the Book of Divine Inspiration?” “Oh, yes! I don’t suppose there’s anyone without that?” “Here’s one with pictures; look at it.” He took down from a shelf a heavy and ponderous volume of the Book of Divine Inspiration, as written and compiled in the planet Lucifram, and carried it without the least apparent effort to the table. “Now come and look at the pictures. I’ll show you a few, and then you can take it away with you and look at the rest.”
  • 55.
    He opened itat the first page—the frontispiece. It was a picture of the Golden Serpent, so lifelike that its appearance was most startling. The book, likewise, must have possessed the property of magnifying all contained in it, for suddenly the head and coils and tails seemed to enlarge to the same gigantic size as that within the temple. “I don’t like it. Don’t show me any more of that book,” Rosalie said. “But why?” he asked, with apparent surprise. “Oh! I don’t know,” she answered, almost whispering. “It’s the Serpent. I don’t like it.” “But you are the young lady who was kissing its head, and throwing your arms around it.” “Yes, I know. That was because I did not understand.” “And now?” “Oh, now! I think it’s cruel and deceitful.” “That’s nothing short of blasphemy. The Serpent is a god!” “Do you believe that?” she asked, suddenly looking up, and fixing his eyes with a look as keen as it was serious. Two pairs of eyes, dark and light, each encountered one another— each trying to read the other’s secret—and both for once inscrutable, dark and light alike. “Yes. I’ve got a pretty good mental digestion; it can take most things,” he said, the corners of his mouth curving into a smile. “Look! Miss—Miss—What’s your name, by the way?” “My name is Rosalie—Rosalie Paleaf.” “Well now, Miss Paleaf, let us turn to the second picture.” Reluctantly she turned round once more, to behold a forest jungle, as fine and beautiful a scene as one could wish. Its size and realism made her put out her hand to pull a twig of feathery foliage, when suddenly she was startled to see beneath it a pair of eyes, wild and yet intelligent, gleaming out at her. It was an animal shaped and sized much like a monkey. Behind it was another of the same kind, a partner in its joys and sorrows evidently. Rosalie sprang back. “Look at that hideous thing!” she cried in horror, pointing to it. Then recollecting herself, she said, with an effort at more self-control
  • 56.
    and appreciation: “Are—arethey extinct now?” “I don’t know, I’m sure. What would you say?” “I sincerely hope so, I’m sure. Put it away. There is something uncanny about that book. That creature startled me.” “It’s an acquired taste. Here we come to another.” He had turned onward to a third picture, in which was shown a woman sitting on the roots of a tree, the expression of her face long and uncompromising, full of discontent. She wore no clothing, but her long and silky hair was sufficient covering. She was of no particular beauty, and her expression of discontent, mingled with curiosity, subtly introduced, and having little intelligence to enlighten it, gave the girl a feeling of repugnance. In one hand she held a fruit of brilliant scarlet; a mouthful was being eaten, and its taste did not seem altogether to her liking. “What do you think of this?” “I like it very little better. The man who painted it, judging from her face, understood human nature, and had very little mercy for it.” “There you are mistaken. It is a caricature,” he answered softly, “painted one day by a man, and sent to his dearest friend—a woman.” “But she is eating a tomato.” “Of course! Let us continue.” The next picture showed this same woman standing beside a man who sat upon a rock cracking nuts with his teeth. As Rosalie looked the scenes began to move and become lifelike, pretty much in the same way as a cinematograph. At first the man did not perceive his companion, but turning suddenly, in the act of taking a broken shell from his mouth, he saw her holding the scarlet fruit, from which she had taken no more than two fair mouthfuls. On seeing this his jaw dropped, his eyes expanded. Thin, far-away voices came from the picture, aiding the illusion. “What for did you that?” said he, in a voice devoid of beauty and expression. “To find out,” she replied, in the same manner. “But we die—we die—if we eat fruit of blood colour!” he cried, with superstitious horror in his voice.
  • 57.
    “We no die,we live and grow fat. I eat, I live; but I miss something.” “What?” “I know not. Eat, and tell me.” Her look was cunning. “I dare not.” “It is the best of all kinds—but for one thing.” “And what is dat?” “Eat, and tell me. You be my faithful love.” Gingerly he took it in his hand, applied it reluctantly to his lips, sucking the juice alone. “It wants—” His low forehead wrinkled. He could not formulate his thoughts. “What?” “It wants—” And then all round a million voices echoed: “It wants but salt!” “Salt!” he shouted, drowning the harmonic voices in his new discovery. Hereupon the woman fell upon her knees, and almost worshipped him, kissing his hands and feet, weeping tears of pleasure on them. “Scrape me some up,” he uttered, taking advantage of her low position. She did it with her finger-nails. “Now stand back whilst I eat it.” “But I—I found it.” “Stand back, goose, and watch me eat.” “I found it first,” she whimpered. “Here’s a seed—that’s all you’re worth,” he answered. “Now I go to find more,” said he, jumping up valiantly. “You bake bread and get me butter for when I return.” “I come too!” she cried. “You eat the whole while I worky work.” “Fool—toad—weasel—monkey! bake me the bread, or I your neck am breaking!”
  • 58.
    And with thatthey disappeared from the page. Only the picture in its first stage remained visible. “That’s not pretty at all,” said Rosalie. “Few things are in real life,” he answered. “But that was caricature.” “Not in the way you think. It was caricature, I grant, but with a difference.” “Yes. I don’t think the eating of salt with tomato could make a man really superior, do you?” “No; but it was the fact that he discovered salt.” “But he didn’t. He was as ignorant as she till the voices whispered it.” “Nevertheless, he caught the first sound.” “Yes, of course,” said Rosalie thoughtfully. Here Mr. Barringcourt laughed. “You do not appreciate its true absurdity,” he said; “but that, maybe, is scarcely necessary. Now, that picture, or series of pictures, was painted by a woman, and sent to the man who had sent her the first.” “But how about the voices?” “Oh! she was no ordinary woman, by any means.” “Was she quarrelling with the man?” “No. They were amusing each other in wet weather.” “They paint most beautiful scenery, but I don’t like their men and women.” “You are not intended to. Now, shall we go on?” “No; I’d rather not, really. It gives me headache, and I’ve had it ever since yesterday afternoon, except for that little bit after you had healed me.” “You are tired of the Book of Divine Inspiration?” “I’m tired of the pictures; they are no better than caricatures and skits. I don’t think that’s a good book to keep in a house at all.” “You astound me! Were you not brought up to worship the Serpent?”
  • 59.
    “Yes; but theSerpent disappointed me.” “I see. You only worship a God who is content to spoil you?” She shook her head. “I don’t know,” she said. “Perhaps I’ll settle down again before long.” “I hope so. Has it ever struck you, Miss Paleaf, how completely you are in my power?” “No,” she answered, looking at him quickly. “Well, you know, I found you in the temple, in the Holiest Place— the place forbidden to women. Do you know what the punishment for that transgression is?” “No.” “To have your tongue torn out by the roots.” “Impossible!” “Not in the least. In this one interview with me you have said enough against the Serpent to set all its scales and coils bristling, and its fangs working.” “I have said nothing.” “‘Cruel and deceitful,’ were not those your words?” “Yes; but to tear my tongue out would not be to prove it otherwise. The Serpent’s wisdom should assert itself and prove the opposite. You were also in the Holiest Place.” “Of course; but for a man the offence is not so capital.” “Tomatoes and salt,” said Rosalie, and she laughed. He laughed also. “Your impudence is only beaten by your ignorance.” “As often as I offend solely with my tongue, you must take the blame yourself. I think you must have oiled the wheels too freely.” “It is a good thing you have no relatives, Miss Paleaf; they would have missed you, disappearing so suddenly.” “Under the circumstances, I suppose it is.” “Were you happy with them?” “Oh, yes! As happy as the day, when we were in prosperity. But this last year has been nothing but shadow and poverty, and I don’t
  • 60.
    Welcome to ourwebsite – the perfect destination for book lovers and knowledge seekers. We believe that every book holds a new world, offering opportunities for learning, discovery, and personal growth. That’s why we are dedicated to bringing you a diverse collection of books, ranging from classic literature and specialized publications to self-development guides and children's books. More than just a book-buying platform, we strive to be a bridge connecting you with timeless cultural and intellectual values. With an elegant, user-friendly interface and a smart search system, you can quickly find the books that best suit your interests. Additionally, our special promotions and home delivery services help you save time and fully enjoy the joy of reading. Join us on a journey of knowledge exploration, passion nurturing, and personal growth every day! testbankmall.com