ET tubes and Peep

[gonefishing]

Anyone have any thoughts or input on this? LOL

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[Carlos Danger]

Normal physiologic PEEP is around 2, but I don't know that the glottis is the primary cause of that resistance to expiratory flow.

I also don't know that the resistance offered by an ETT and ambu bag can't equal the resistance of the glottis. Maybe, maybe not. Too many variables, I think, to make such a blanket statement.

 

[VentMonkey]

Ah, to PEEP or not to PEEP that is the question...

So we just sat through a weeks worth of in-service on our new ventilator, and in talking with the rep providing our in-service, it would appear thaf PEEP as a whole really isn't as harmful as once suspected. Are there still parts of the country, or providers apprehensive to dial PEEP up to say 20? Sure.

I am sure that there are others on here that can break it down further or pull up some studies citing the relationship of the ET tube and it's relevance to PEEP, but for what it's worth, I think that is a poorly worded question.

 

[E tank]

Isn't physiologic PEEP a mean of alveolar pressure averaged over inspiration and expiration? So on inspiration Palv would be -3 and expiration it would be 5 as an example....I'd think it would take more than an ETT let alone vocal cords to have any clinically relevant effect on PEEP. I guess I'd sum it up by saying "who cares?"

What'd I miss?

 

[E tank]

Ah, to PEEP or not to PEEP that is the question...

So we just sat through a weeks worth of in-service on our new ventilator, and in talking with the rep providing our in-service, it would appear that PEEP as a whole really isn't as harmful as once suspected. QUOTE]

I'd go so far as to say than no PEEP is harmful. In healthy lungs, I'm finding myself giving 8 of PEEP as a matter of routine, or as directed by measured by auto-peep if I have the capability with diseased lungs.

 

[VentMonkey]

I'd go so far as to say I absolutely agree, but for whatever reason, in my region this thought process is still not all that well recepted.

 

[Carlos Danger]

I wouldn't say no PEEP is harmful. Certainly in someone with healthy lungs, it's pretty hard to hurt them. But generally speaking, the lowest pressure you can use and keep full recruitment, the better.

 

[E tank]

I wouldn't say no PEEP is harmful. Certainly in someone with healthy lungs, it's pretty hard to hurt them. But generally speaking, the lowest pressure you can use and keep full recruitment, the better.

I think the idea of atelectrauma from alveolar instability over the respiratory cycle is behind the strategies of avoiding ventilator induced lung injury. Without PEEP, when the atelectasis occurs, the alveoli "pop" open causing shear stress and inflammation. Over time it causes lung injury.

 

[Carlos Danger]

I think the idea of atelectrauma from alveolar instability over the respiratory cycle is behind the strategies of avoiding ventilator induced lung injury. Without PEEP, when the atelectasis occurs, the alveoli "pop" open causing shear stress and inflammation. Over time it causes lung injury.

Little misunderstanding on my part here.

A few posts up someone said "I'd go so far as to say that no PEEP is harmful". Because that statement was followed up with "I use 8 of PEEP as a matter of routine", I thought what was meant by "no PEEP is harmful" was "even very high levels of PEEP are not harmful", rather than "PEEP of 0 is harmful".

So when I wrote "I wouldn't say no PEEP is harmful", what I meant was "I wouldn't say that unnecessarily high levels of PEEP can't contribute to harm". My bad.

ARDSnet does call for starting at a PEEP of 5 and basically only increasing it as necessary - just like fi02 - with the reasoning being that mean airway pressure should ideally be kept low. The only time I use more than 5 in the OR is if they need it because their lungs are bad, or during laparoscopic cases when the abdomen is insufflated, especially when they are obese, and especially when they are in a head-down position, and in those cases I generally start at 8. But of course I've used much higher than that, both in anesthesia and during transport.

 

[gonefishing]

Little misunderstanding here.

A few posts up someone said "I'd go so far as to say that no PEEP is harmful". Because that statement was followed up with "I use 8 of PEEP as a matter of routine", I thought what was meant by "no PEEP is harmful" was "even very high levels of PEEP are not harmful", rather than "PEEP of 0 is harmful".

So when I wrote "I wouldn't say no PEEP is harmful", what I meant was "I wouldn't say that unnecessarily high levels of PEEP can't contribute to harm".

My bad.

ARDSnet does call for starting at a PEEP of 5 and basically only increasing it as necessary,- just like fi02 - with the reasoning being that mean airway pressure should ideally be kept as low. The only time I use more than 5 in the OR is if they need it because their lungs are bad, or during laparoscopic cases when the abdomen is insufflated, especially when they are obese, and especially when they are in a head-down position, and in those cases I generally start at 8. But of course I've used much higher than that, both in anesthesia and during transport.

Thank you so much for your input!

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[VentMonkey]

I don't know if it's current trends or not, but what I was referring to was the increases in PEEP patients are being left at depending on their condition, and the fact that they're finding that these increases---even if sustained---don't necessarily produce the level of volutrauma or barotrauma which once suspected, prevented such patients from receiving higher PEEP parameters in order to improve oxygenation.

https://www.ncbi.nlm.nih.gov/m/pubmed/23740697/

 

[ExpatMedic0]

Anyone have any thoughts or input on this? LOL

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Regarding the icon in the upper left-hand corner, I also play StarWars commander. Looks like "Your troops are ready commander."

 

[gonefishing]

Regarding the icon in the upper left-hand corner, I also play StarWars commander. Looks like "Your troops are ready commander."

LOL!!!!!!!!

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[E tank]

I don't know if it's current trends or not, but what I was referring to was the increases in PEEP patients are being left at depending on their condition, and the fact that they're finding that these increases---even if sustained---don't necessarily produce the level of volutrauma or barotrauma which once suspected, prevented such patients from receiving higher PEEP parameters in order to improve oxygenation.

https://www.ncbi.nlm.nih.gov/m/pubmed/23740697/

One of the problems with teasing out issues like "low" tidal volumes and varying PEEP is how these things are defined in various studies. They differ quite a bit from study to study. Consensus (for what it's worth) seems to be "some PEEP" and peak pressures less than 30 to avoid VILI, most of which comes from the ARDS net protocols. But those protocols are for folks with lung injury, so applying that to patients that don't is sort of up for grabs. So for me, 7 ml per kg PBW and 8 of PEEP and .4-.6 fiO2 is my routine for "healthy" patients.

 

[VentMonkey]

One of the problems with teasing out issues like "low" tidal volumes and varying PEEP is how these things are defined in various studies. They differ quite a bit from study to study. Consensus (for what it's worth) seems to be "some PEEP" and peak pressures less than 30 to avoid VILI, most of which comes from the ARDS net protocols. But those protocols are for folks with lung injury, so applying that to patients that don't is sort of up for grabs. So for me, 7 ml per kg PBW and 8 of PEEP and .4-.6 fiO2 is my routine for "healthy" patients.

Yes, our current ventilator protocols dictate managing patients based on their condition, whether suspected or confirmed

Again, with no clinical insight it would appear to me that one doesn't have much business dealing with ventilator management, let alone adjusting parameters on their own.