# What vent mode is best?



## truetiger (Apr 29, 2013)

The facilities near us don't even bother sedating intubated patients....its almost criminal. They'll leave a fully alert and aware patient on assist/control.


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## Clipper1 (Apr 29, 2013)

truetiger said:


> The facilities near us don't even bother sedating intubated patients....its almost criminal. They'll leave a fully alert and aware patient on assist/control.



That depends on the disease process. For some over sedated and using a paralytic might sound "criminal".

Assist Control is also one of the most common and comfortable modes to be in if you are awake and definitely if you are on a transport ventilator.  The ventilator will assist with every breath.


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## Ecgg (Apr 29, 2013)

Clipper1 said:


> Assist Control is also one of the most common and comfortable modes to be in if you are awake and definitely if you are on a transport ventilator.  The ventilator will assist with every breath.



:unsure: That is news to me.


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## Clipper1 (Apr 29, 2013)

Ecgg said:


> :unsure: That is news to me.



Many of the long term patients are on it in SubAcutes and home care.

ARDS patients and anybody admitted in distress will be placed on it. 

It offers full support with a delivered preset VT.


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## usalsfyre (Apr 29, 2013)

Ecgg said:


> :unsure: That is news to me.


A/C is the mode of choice for the majority of patients. SIMV gives too wide a variety of breaths and has been found to increase weaning time over a combo of A/C and CPAP+PS


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## Ecgg (Apr 29, 2013)

usalsfyre said:


> A/C is the mode of choice for the majority of patients. SIMV gives too wide a variety of breaths and has been found to increase weaning time over a combo of A/C and CPAP+PS



Yes, A/C is the starting mode of choice although is it suited for awake patients? Pretty much every text I have, they list one of the disadvantages of A/C is patient ventilator dyssynchrony in awake patients.


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## usalsfyre (Apr 29, 2013)

Ecgg said:


> Yes, A/C is the starting mode of choice although is it suited for awake patients?



Yeah, I've transported a ton of long term trachs on A/C. Far more comfortable than being air hungry on SIMV.


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## Ecgg (Apr 29, 2013)

usalsfyre said:


> Yeah, I've transported a ton of long term trachs on A/C. Far more comfortable than being air hungry on SIMV.



Long term trach patients should not be on A/C. I know they place them on A/C but that is not correct. They should be on SIMV with Pressure support, they are air hungry on SIMV if you do not provide proper pressure support to them


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## Carlos Danger (Apr 29, 2013)

usalsfyre said:


> I'm pretty  studied on pressors. I'm not aware of any that aren't ideally delivered through a central.



Ideally, yes. But it's definitely not mandatory by any means, especially at the more commonly used half-concentrations, and especially if you aren't on huge doses.

Even if you were on a larger dose, in the short time that most transports take, as long as you are careful to make sure the PIV doesn't get pulled on, neo, levi, or dopa should be perfectly fine through a PIV.


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## truetiger (Apr 29, 2013)

How is a/c ideal for patients that are awake? If they're air hungry on SIMV then increase the back up rate. I can see it working for long term trach patients who are accustomed to mechanical ventilation, but not the medical pt who just got RSI'd.


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## RocketMedic (Apr 30, 2013)

Weirdly, I generally agree with Clipper1.


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## Merck (Apr 30, 2013)

A/C Vol is certainly common but I'd say that for the awake pt with decent respiratory drive that PSV is generally better tolerated.  Of course, people are adaptable and might settle nicely on different settings.

As for pressors, generally I'd only run dopamine peripherally or phenylephrine in a pinch.  Anything else should go centrally.  Sure you could half-strength some levo but why?  Run it centrally or use an IO if need be.


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## Clipper1 (May 1, 2013)

Ecgg said:


> Long term trach patients should not be on A/C. I know they place them on A/C but that is not correct. They should be on SIMV with Pressure support, they are air hungry on SIMV if you do not provide proper pressure support to them



The key is "long term" trach patients. That means they are ventilator dependent and not weaning.

You need to look at the wave form graphs and check out the flows. SIMV is a weaning mode and not used very often for that either. Unfortunately it seems the text books you might be referencing might be about 30 years out of date.


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## Clipper1 (May 1, 2013)

Merck said:


> A/C Vol is certainly common but I'd say that for the awake pt with decent respiratory drive that PSV is generally better tolerated.  Of course, people are adaptable and might settle nicely on different settings.



Why would you be placing a CCT patient on PSV?  You should not be screwing around thinking you can get the patient extubated before the next hospital.


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## Clipper1 (May 1, 2013)

truetiger said:


> How is a/c ideal for patients that are awake? If they're air hungry on SIMV then increase the back up rate. I can see it working for long term trach patients who are accustomed to mechanical ventilation, but not the medical pt who just got RSI'd.



Why would you use a weaning mode on a patient who just got RSI'd.  Their confusion waking up with the variation in flows would be detrimental to their ventilator synchrony.  How would you even determine the idea PSV setting on a paralyzed patient when they wake up?


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## VFlutter (May 1, 2013)

Clipper,

The button directly to the right of the "Quote" button is the multi-quote button. You can click that on as many posts as you want and then click the "Quote" button allowing you to reply to all in a single post. It is much cleaner and easier to follow. 

Just FYI


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## Clipper1 (May 1, 2013)

Chase said:


> Clipper,
> 
> The button directly to the right of the "Quote" button is the multi-quote button. You can click that on as many posts as you want and then click the "Quote" button allowing you to reply to all in a single post. It is much cleaner and easier to follow.
> 
> Just FYI



Thanks. I tried that a couple of times and lost all I had written.  But, I'll try it again if needed.


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## Ecgg (May 1, 2013)

Clipper1 said:


> The key is "long term" trach patients. That means they are ventilator dependent and not weaning.
> 
> You need to look at the wave form graphs and check out the flows. SIMV is a weaning mode and not used very often for that either. Unfortunately it seems the text books you might be referencing might be about 30 years out of date.





Clipper1 said:


> Why would you use a weaning mode on a patient who just got RSI'd.  Their confusion waking up with the variation in flows would be detrimental to their ventilator synchrony.  How would you even determine the idea PSV setting on a paralyzed patient when they wake up?



A true Assist Control mode is not synchronized with the patient breathing. Thus breath stacking and patient ventilator dyssynchrony will occur if the patient is not sedated and is fully awake. Place ETCO2 on awake patient on assist control mode and see the numbers go down due to that.

RSI patient can go on A/C no problem, you stated awake patients should be on A/C, and I disagree. 

SIMV is not only used for weaning trials.


Essentials of Mechanical Ventilation, Second Edition [Hardcover]
Dean Hess (Author), Robert Kacmarek (Author)


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## Clipper1 (May 1, 2013)

Ecgg said:


> A true Assist Control mode is not synchronized with the patient breathing. Thus breath stacking and patient ventilator dyssynchrony will occur if the patient is not sedated and is fully awake. Place ETCO2 on awake patient on assist control mode and see the numbers go down due to that.
> 
> RSI patient can go on A/C no problem, you stated awake patients should be on A/C, and I disagree.
> 
> SIMV is not only used for weaning trials.



Modern ventilators are designed to with sensitivity levels to be set. If your patients are out of synch in an AC mode, you need to adjust the sensitivity and check the termination flow setting.

AC in both the volume and pressure modes is the most common since it does as its name states "assist".  

ETCO2 numbers going down can be a good thing. It means the patient is *ventilating* which is the purpose of a ventilator.  Being out of synch would cause the numbers to increase with air trapping. I will state again to use the graphs.  If the patient is breathing too fast, you need to assess pain levels and the meds you are using for a critically ill patient before you blame the technology. 

We run ETCO2 on most of our ventilator patients in the ICU and EDs so I do have an idea about vent modes and their relationship with ventilation and oxygenation. 

I see no purpose in putting a patient in SIMV with one breath at 500 and another at maybe 100 or 200 ml especially when acutely ill and variations in compliance. No patient with a plateau pressure above 30 should ever have to struggle to take a breath on PSV. But, how are you going to determine plateau pressure on most transport ventilators?

EDIT:
Your last post made our points concerning the difference between the modes a little clearer. If a patient has decreasing it would be more beneficial to have a set VT given which would also give a better indication that a different mode of higher ventilation is needed.  If you are transport without a graphic monitor, you can at least tell by the PIPs that your patient needs attention. If in SIMV with PSV you may not realize that the VTs in PS are next to nothing and the patient is struggling for their spontaneous breaths. In AC, that is not a problem. If the patient is asynch, check your patient, meds and the settings.


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## Ecgg (May 1, 2013)

Clipper1 said:


> Modern ventilators are designed to with sensitivity levels to be set. If your patients are out of synch in an AC mode, you need to adjust the sensitivity and check the termination flow setting.
> 
> AC in both the volume and pressure modes is the most common since it does as its name states "assist".
> 
> ...



Sensitivity is not the issue here: in A/C you can provide assisted breath however they are not in synch to patient own respiratory effort. That means if awake patients triggers A/C for an extra breath and ventilator provides it and the next scheduled A/C breath falls right after it timing wise the patient will get breath stacked. SIMV accounts for that and adjusts the timing hence more preferred for awake patients.  SIMV does not just mean weaning trial mode.

Hence why S in SIMV stands for synchronized. There is no synchrony in A/C.


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## Clipper1 (May 1, 2013)

Ecgg said:


> Sensitivity is not the issue here: in A/C you can provide assisted breath however they are not in synch to patient own respiratory effort. That means if awake patients triggers A/C for an extra breath and ventilator provides it and the next scheduled A/C breath falls right after it timing wise the patient will get breath stacked. SIMV accounts for that and adjusts the timing hence more preferred for awake patients.  SIMV does not just mean weaning trial mode.
> 
> Hence why S in SIMV stands for synchronized. There is no synchrony in A/C.



The S in SIMV came out about 35 years ago after older ventilators were only IMV.  

Here is a better chapter with pictures of graph patterns.  This is Hess' book which you did not provide the full text from your quotes.

http://samples.jbpub.com/9781449655594/60038_CH22_462_500.pdf


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## Clipper1 (May 1, 2013)

Ecgg said:


> *Sensitivity is not the issue here*: in A/C you can provide assisted breath however they are not in *synch to patient own respiratory effort.* That means if awake patients triggers A/C for an extra breath and ventilator provides it and the next scheduled A/C breath falls right after it timing wise the patient will get breath stacked. SIMV accounts for that and adjusts the timing hence more preferred for awake patients.  SIMV does not just mean weaning trial mode.
> 
> Hence why S in SIMV stands for synchronized. There is no synchrony in A/C.



I forgot to mention: Sensitivity is how you set the resistance to triggering the ventilator in either  flow or pressure triggered.  If you are stacking your check the triggering, fixed flow rate and termination flow.  Sometimes on the transport ventilators flow is determined by I-time.  Sensitivity is an issue everytime unless the patient is on a paralytic.


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## Ecgg (May 1, 2013)

Clipper1 said:


> I forgot to mention: Sensitivity is how you set the resistance to triggering the ventilator in either  flow or pressure triggered.  If you are stacking your check the triggering, fixed flow rate and termination flow.  Sometimes on the transport ventilators flow is determined by I-time.  Sensitivity is an issue everytime unless the patient is on a paralytic.



That is a great pdf, thank you for the link. Although I was using a different book it's title is Essentials of Mechanical Ventilation.

If you adjust the triggering all that does is either allow an easier trigger or more effort on patient part to trigger a breath.

Let me type it out, maybe this will be more clear.


For example we set the ventilator
*A/C  RR: 10, Tv: 500ml* 
Patient will get mandatory breath every 6 seconds with 500ml TV no matter what. However, if the patient wants to take his own breath at second 4-5 the ventilator gives him full 500ml breath and gives another  scheduled one on second 6 mark with 500ml. Thus the patient just received 2 breaths back to back and he may not have even fully exhaled the first breath. Ie breath stacked. This is what happens when the patient is fully awake, not sedated on A/C.

*SIMV RR 10 Tv: 500ml PS 10*
Patient will get mandatory breath every 6 seconds with 500ml TV no matter what. However if the patient wants to take his own breath at second 4-5 the ventilator gives him the breath and adjust the next scheduled mandatory breath further away from just given breath. Thus the patient gets to fully exhale and less chance he will get breath stacked.


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## Clipper1 (May 1, 2013)

You will note that is the same author as the book you quoted. I just included one whole chapter rather than a few sentences which can be taken out of context of a broader explanation. Also, this was chapter 22. That means there are at least 21 other chapters leading up to this one chapter. There are more discussing much more about patient comfort and therapies on a ventilator. The section on the indepth use different gases had still not be reached.



Ecgg said:


> For example we set the ventilator
> *A/C  RR: 10, Tv: 500ml*
> Patient will get mandatory breath every 6 seconds with 500ml TV no matter what. However, if the patient wants to take his own breath at second 4-5 the ventilator gives him full 500ml breath and gives another  scheduled one on second 6 mark with 500ml. Thus the patient just received 2 breaths back to back and he may not have even fully exhaled the first breath. Ie breath stacked. This is what happens when the patient is fully awake, not sedated on A/C.



This is where your understanding of AC either in Pressure or Volume is faulty.
This is the definition of IMV which is the original form of CMV (Controlled Mandatory Ventilation). In AC (VAC or PAC) the patient wants 16 breaths instead of 10, they will get 16 breaths all delivered at the same consistent volume or pressure and flow unless it is an ICU machine which has the ability to predetermine the flow to meet patient's demands or compliance issues.

Probably the purpose of that example is to teach the basics of a ventilatory cycle so you understand I:E ratios. Beyond that the material progresses to how ventilators actually deliver breaths to a patient. This is just a basic calculation. The only time you will see a static I:E ratio like that will be on a dead or paralyzed (pharmacology or some physical reason).

 A few of the ATVs which ambulances carry might be CMV but many are also Assist Control with a demand trigger.

ASSIST means just that. *Every* breath initiated with be given a set VT or Pressure *anytime* the patient wants it. That is the control part.  Yes the sensitivity to trigger that ventilator is very, very important. You do not want the patient to struggle.

The other major factor to consider on a transport is safety. Compliance can change. PSV is not the mode that you can readily identify that on many transport ventilators. Delivering an acidotic patient to the ICU from hypoventilation or fatigue is not good.

This is why experience in critical care watching at least 2 patients for 8 or 12 hours every worked shift is of great value.  Many CC RNs will have over 60 ventilator patient hours every week if they only work 12 hour shift.  Even with that it is recommended they have at least 2 - 5 years of experience seeing all they can in the various different units since every type of patient will require a different clinical pathway for ventilation and sedation.  Then to have the ability to translate this to a single limb transport ventilator, which they do probably every shift taking the patient to procedures, is yet another educational process.


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## truetiger (May 1, 2013)

So how is this better than SIMV w/PSV? In a/c you'll get your mandatory rate and be allowed to over breathe  the vent, however the vent will deliver the extra breathes with the full tidal volume, out of sync. In SIMV you'll still get your mandatory rate at minimum and can over breathe the vent as well, however; the ventilator will sync with your breaths and deliver adjusted tidal volumes.


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## Aidey (May 1, 2013)

I have move the ventilator discussion from the central line thread here. Please keep the discussion of vents out of the central line thread.


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## Clipper1 (May 1, 2013)

Maybe a critical care discussion should be more appropriate.

What types of lines and meds do you have available?  This discussion was started in the Central Line topic but the two are also related. When these same topics are discussed on critical care forums involving many different professionals, a broader range of issues are presented so that the "best mode" is applied to what suits the patient. 

I do see in part this being the problem with overview courses which introduce topics but are too short to dive into much depth or discuss the actual management of a patient from all aspects of care which must all be considered. This includes disease process, medications, lines, acute and chronic issues including renal, cardiac and pulmonary failure.


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## Aidey (May 1, 2013)

No one is saying you can't have a multi-topic discussion on critical care issues. I'm just saying you can't have it in the central line thread. If you want to discuss multiple critical care issues in the same thread, start it yourself.


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## Clipper1 (May 1, 2013)

truetiger said:


> So how is this better than SIMV w/PSV? In a/c you'll get your mandatory rate and be allowed to over breathe  the vent, however the vent will deliver the extra breathes with the full tidal volume, out of sync. In SIMV you'll still get your mandatory rate at minimum and can over breathe the vent as well, however; the ventilator will sync with your breaths and deliver adjusted tidal volumes.




Nothing is out of synch when the breath is delivered when the patient initates the ventilator. 

For SIMV, especially for transport ventilators, you have a mandatory breath which is given at a fixed flow and a declerating waveform. For PSV you have more of a square way with a rapid acceleration which might terminate quicker or even be prolonged (which can cause air trapping).  The PSV  breath might only provide 100 ml of VT when the patient wants and needs 500 ml. Compliance and secretions will play a big factor. If the patient wants 10 L of MV but can only get 5 because of the PSV variations in VT delivery, you will get much more asynchony from a hypoventilated patient.  

Please look at the chapter on ventilators I posted you will see all of this graphically illustrated.


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## Ecgg (May 1, 2013)

Clipper all I read in your post is that “my understanding is faulty” and how much experience you have as a nurse in ICU. Yet you seem not to acknowledge the difference between A/C and SIMV which I have outlined for you.


In SIMV with Pressure Support, I can identify issues just as well as I set appropriate low minute volume alarms based on patient minute volume. Thus you can identify if the pressure supported breaths are not delivering adequate TV.


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## truetiger (May 1, 2013)

Both A/C and SIMV allow the patient to initiate a breath. SIMV compensates for rate and tidal volume. A/C compensates for nothing. 

Lets say you want to make sure the patient gets 12 breaths a minute at 500ml. On A/C you are guaranteed 12 at 500. If the patient wants more, they can initiate the vent. So you're going to get a breath every 5 sec at 500. Lets say the patient takes  a small breath (100ml), at the 4 sec mark that'll trigger the vent initiating the 500ml tidal volume. Now before than can exhale that breath, the vent is going to deliver another 500ml at  the 5 sec mark. This will cause breath stacking if it keeps up.

Now lets look at SIMV. Once again you want 12 at 500. You set your back up rate 12 and your tidal volume. You're guaranteed 12 at 500. Now lets say your patient wants a breath at the 4 sec mark, (100ml again.) The vent will assist the other 400ml and now space out the next breath to synchronize with the patient's respiratory effort to avoid breath stacking. SIMV can also be used in weaning by adding PSV and using a low back up rate.

A/C works great if you're patient is paralyzed (just after RSI) or heavily sedated and does not have a good respiratory drive. Ideal if you're trying to give the respiratory muscles a break.  If you're patient has a decent respiratory drive (and you want that) you're going to need to use SIMV to avoid breath stacking.

I can't tell you have many times when we've gone in for a transfer and the patient is under sedated and on A/C. The patient was RSI'd 2 hours earlier and hasn't received anything for analgesia since. These patient's are obviously hurting. They open their eyes, are lacrimating, bucking the tube, and have a sympathetic response.


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## shfd739 (May 1, 2013)

truetiger said:


> Both A/C and SIMV allow the patient to initiate a breath. SIMV compensates for rate and tidal volume. A/C compensates for nothing.
> 
> Lets say you want to make sure the patient gets 12 breaths a minute at 500ml. On A/C you are guaranteed 12 at 500. If the patient wants more, they can initiate the vent. So you're going to get a breath every 5 sec at 500. Lets say the patient takes  a small breath (100ml), at the 4 sec mark that'll trigger the vent initiating the 500ml tidal volume. Now before than can exhale that breath, the vent is going to deliver another 500ml at  the 5 sec mark. This will cause breath stacking if it keeps up.
> 
> ...



Most of us set all of our vent pt's on SIMV, even the sedated ones that are normally A/C. They get the breaths they are supposed to and if they have a light sedation and trigger one they wont get one stacked right behind it. Our CCT medical director is okay with this and suggested this to us. 

We also have to do a fair bit of resedation here as well. Almost exclusively with ER transfers. The pt gets RSI'd then no more sedation or paralytics. I also had one recently that was a larger male, on a moderate amount of Propofol and the staff didnt want to increase it and didnt get why he was fighting, lacrimating etc. Guy was a heavy drinker and nearly 300lbs; its gonna take alot of Propofol to keep him down; or try something different. Soon as we got him loaded the Propofol went up, added Versed and once he relaxed gave more Vec. 

The wife said he looked comfortable for the first time in 12 hours.


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## truetiger (May 1, 2013)

What's even more disturbing is that we have a band aid station that doesn't even consider doing blood gasses in ventilated patients.


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## Clipper1 (May 1, 2013)

Ecgg said:


> Clipper all I read in your post is that “my understanding is faulty” and how much experience you have as a nurse in ICU. Yet you seem not to acknowledge the difference between A/C and SIMV which I have outlined for you.
> 
> 
> In SIMV with Pressure Support, I can identify issues just as well as I set appropriate low minute volume alarms based on patient minute volume. Thus you can identify if the pressure supported breaths are not delivering adequate TV.



Low MV alarm?  Tell me this is just a joke. That might be okay on a pure PSV mode in the ICU with the CR monitor.  If the VT is hitting your low MV then you have hypoventilated the patient. At what percentage of your set VT is your target PSV VT?  How do you determine Low MV? With just the set VT and then what percentage? What about the spontaneous breaths?

You reasoning that a patient in AC will only receive the amount of breaths set is not correct. Every breath will be at the set VT or PC depending upon VAC or PAC mode.


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## Clipper1 (May 1, 2013)

truetiger said:


> Both A/C and SIMV allow the patient to initiate a breath. SIMV compensates for rate and tidal volume. A/C compensates for nothing.
> 
> Lets say you want to make sure the patient gets 12 breaths a minute at 500ml. On A/C you are guaranteed 12 at 500. If the patient wants more, they can initiate the vent. So you're going to get a breath every 5 sec at 500. *Lets say the patient takes  a small breath (100ml), at the 4 sec mark that'll trigger the vent initiating the 500ml tidal volume. Now before than can exhale that breath, the vent is going to deliver another 500ml at  the 5 sec mark. This will cause breath stacking if it keeps up.*



Incorrect. If you please read the link provided earlier or a decent ventilator book you will see that AC is no longer IMV. All modern ventilators (for the past 25 years) will synch with a delivered breath unless you have failed to set the other parameters correctly such as sensitivity, flow and termination percentages.  The set rate is not fixed to be delivered exactly as you have text book calculated the rate. 



truetiger said:


> Now lets look at SIMV. Once again you want 12 at 500. You set your back up rate 12 and your tidal volume. You're guaranteed 12 at 500. Now lets say your patient wants a breath at the 4 sec mark, (100ml again.) The vent will assist the other 400ml and now space out the next breath to synchronize with the patient's respiratory effort to avoid breath stacking. SIMV can also be used in weaning by adding PSV and using a low back up rate.
> 
> A/C works great if you're patient is paralyzed (just after RSI) or heavily sedated and does not have a good respiratory drive. Ideal if you're trying to give the respiratory muscles a break.  If you're patient has a decent respiratory drive (and you want that) you're going to need to use SIMV to avoid breath stacking.
> 
> I can't tell you have many times when we've gone in for a transfer and the patient is under sedated and on A/C. *The patient was RSI'd 2 hours earlier and hasn't received anything for analgesia since*. These patient's are obviously hurting. They open their eyes, are lacrimating, bucking the tube, and have a sympathetic response.



Again look at the flow patterns. Every ventilator text book will explain the differences to you.  

The example you have posted about RSI is just criminal. If this is your patient please, please learn more about ventilator management. 

If you RSI a patient, you really should NOT alloow the patient to just wake up abruptly. With any paralytic you should also be sedating. If the patient is bad enough to require RSI, you need to keep that tube and this means keeping adquate sedation. There is absolutely no reason for a patient to ever become wide awake after intubation in an emergent situation. 

I have to ask, where are you getting your ventilator training from?


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## Clipper1 (May 1, 2013)

shfd739 said:


> Most of us set all of our vent pt's on SIMV, even the sedated ones that are normally A/C.



If the patient has a plateau pressure over 34 or even just secretions, what do you think that PSV breath is going to do. There is a reason why come patients are on AC.  

I also hope everyone here realizes AC (Asist Control) applies to both Volume and Pressure modes.


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## Clipper1 (May 1, 2013)

What if you have a patient at the hospital on AC? Would you automatically just change to SIMV because YOU like it better? 

What about patients who are on HFOV, HJV or APRV?  Is SIMV also going to be your mode of choice?


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## shfd739 (May 1, 2013)

Clipper1 said:


> If the patient has a plateau pressure over 34 or even just secretions, what do you think that PSV breath is going to do. There is a reason why come patients are on AC.
> 
> I also hope everyone here realizes AC (Asist Control) applies to both Volume and Pressure modes.



Im thinking by PSV you mean pressure support? 

We rarely have pressure support patients.


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## shfd739 (May 1, 2013)

Clipper1 said:


> What about patients who are on HFOV, HJV or APRV?  Is SIMV also going to be your mode of choice?



Ive never heard of or seen these in use.


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## Ecgg (May 1, 2013)

Clipper I think you are misinterpreting what is being said. We are discussing pure mode A/C and SIMV and what you are giving an example of is actually  PRVC

Modern ventilators can combine various parameters and modes together, however that is no longer what we are discussing here. Certainly a hospital ventilator will be much more sophisticated than a transport ventilator. However as I stated we are looking what pure A/C mode and SIMV mode.

The definitions provided are very sound. Perhaps you can do a consult with RTT about this.


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## truetiger (May 1, 2013)

This is the hospital's doing prior to our arrival. Our patient's are properly sedated/paralyzed  upon our arrival.


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## Clipper1 (May 1, 2013)

Ecgg said:


> Clipper I think you are misinterpreting what is being said. We are discussing pure mode A/C and SIMV and what you are giving an example of is actually  PRVC



PRVC? Not even close. That is a special mode on ventilators which determines compliance and adjusts pressures to deliver a VT.

PC (Pressure Control) is a very common mode. You will find it on just about every transport ventilator. If anyone here is using the LTV, notice it gives a choice of Volume or Pressure on one button and Assist Control or SIMV on another button. Assist Control and SIMV both pertain to Volume and Pressure modes. If you are doing any type of CCT you really should have someone show you this on your ventilator and explain it. 



Ecgg said:


> The definitions provided are very sound. Perhaps you can do a consult with RTT about this.


 Didn't you read what you posted for quotes from HESS and did you bother to read his full chapter.


I doubt if you want any of the ICU RRTs who have read  this to respond since most of them have read Hess and McIntyre.

BTW, the author (Hess) of that definitions you referenced is an RRT (Respiratory Therapist).  The explanations I am giving are straight from his material.


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## Clipper1 (May 1, 2013)

truetiger said:


> This is the hospital's doing prior to our arrival. Our patient's are properly sedated/paralyzed  upon our arrival.



Do you use the hospital's settings or just put them on SIMV because that is what you like regardless of patient needs.


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## truetiger (May 1, 2013)

Clipper1 said:


> Do you use the hospital's settings or just put them on SIMV because that is what you like regardless of patient needs.


 They were sedated and paralyzed, per our medical director, then put on our AutoVent. It's an uphill battle getting the admin to buck up for a nice transport vent. 

The way you've been describing A/C is like SIMV with a set tidal volume.


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## Dwindlin (May 1, 2013)

truetiger said:


> They were sedated and paralyzed, per our medical director, then put on our AutoVent. It's an uphill battle getting the admin to buck up for a nice transport vent.
> 
> *The way you've been describing A/C is like SIMV with a set tidal volume.*



That's because in modern ventilators it pretty much is, and the only reason to choose one over the other is _user_ comfort with settings.


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## Clipper1 (May 1, 2013)

Dwindlin said:


> That's because in modern ventilators it pretty much is, and the only reason to choose one over the other is _user_ comfort with settings.



Not even close unless the patients are paralyzed  with 0 spontaneous breathing.

Please read and LOOK at the graphics in the chapter linked to.

Does anyone here use a graphic monitor on their transport ventilator. If you did the difference should be very obvious if you had even seen both modes used. 


At some point you must think about the patient and all the many different diease processes. You might need to get out of your comfort zone and learn what all the other settings are  on the ventilator.  It also sounds like sensitivity, I-time, rise, termination or any of the other settings are considered when setting up a ventilator even in SIMV.  To use only a volume mode is also very short sighted since there are several reasons for using PCV in either AC or SIMV.  PCV is not PRVC in most standard transport ventilators or even ICU vents.

To use only one mode is like saying you can only intubate with a Mac blade.


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## Clipper1 (May 1, 2013)

truetiger said:


> They were sedated and paralyzed, per our medical director, then put on our AutoVent. It's an uphill battle getting the admin to buck up for a nice transport vent.
> 
> The way you've been describing A/C is like SIMV with a set tidal volume.




AC is a set tidal volume or a set pressure if you are using PCV (PAC). 

AC modes are in synch with the patient on all modern ventilators. SIMV is a term which has stuck since the 1970s long before modern ventilators.  But, depending on which Autovent you are using, I would say that is more like an old IMV machine with very little synch. Which ATV are you using and we will discuss it?   Are these ICU patients you are transporting IFT by AutoVent?


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## Dwindlin (May 1, 2013)

Clipper1 said:


> Not even close unless the patients are paralyzed  with 0 spontaneous breathing.
> 
> Please read and LOOK at the graphics in the chapter linked to.
> 
> ...



The only difference between SIMV and A/C on the vents I work with is in SIMV not every breath is assisted (volume wise), where as A/C they are.

In this situation it matters very little for meaningful outcomes which you choose.


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## Clipper1 (May 2, 2013)

Dwindlin said:


> The only difference between SIMV and A/C on the vents I work with is in SIMV not every breath is assisted (volume wise), where as A/C they are.
> 
> In this situation it matters very little for meaningful outcomes which you choose.



What type of patients are you transporting? Ventilator settings make a big differences, as does the type of ventilator, for critically ill patients.

As far the Autovent which was mentioned earlier by another, this vent probably should have very limited uses like getting a nearly dead patient to the hospital and freeing up the Paramedics' hands.  Reading about it is kinda scary if its use is attempted on CCT with an ICU patient. Yes this patient would have to be on a paralytic which also brings up issues about plugged or dislodged ETTs in transports. 

Autovent
http://www.emergency-safe.com/inservices/IST 2011/February/Module 5 Autovent 3000 set up and use.pdf


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## Dwindlin (May 2, 2013)

Clipper1 said:


> What type of patients are you transporting? Ventilator settings make a big differences, as does the type of ventilator, for critically ill patients.
> 
> As far the Autovent which was mentioned earlier by another, this vent probably should have very limited uses like getting a nearly dead patient to the hospital and freeing up the Paramedics' hands.  Reading about it is kinda scary if its use is attempted on CCT with an ICU patient. Yes this patient would have to be on a paralytic which also brings up issues about plugged or dislodged ETTs in transports.
> 
> ...



Not transporting them anywhere.  And beyond lung protective strategies for lung injury processes and increased expiratory times for obstructive processes I'm afraid that the details just don't matter much in terms of getting your patient off the blower as quickly as possible.


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## Clipper1 (May 2, 2013)

Dwindlin said:


> Not transporting them anywhere.  And beyond lung protective strategies for lung injury processes and increased expiratory times for obstructive processes I'm afraid that the details just don't matter much in terms of getting your patient off the blower as quickly as possible.



Off the blower?

Is this how you view ventilators?  

Are you saying all of this based only on an inservice on ventilators given to you by a sales rep to sell your agency on their ventilator?  

Since you brought up lung protective strategies what ventilators are you using?  What about restrictive processes or acute diseases which can present with ARDS?   Have you ever been in an LTACH?


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## Dwindlin (May 2, 2013)

Clipper1 said:


> Off the blower?
> 
> Is this how you view ventilators?
> 
> ...



Puritan Bennett 840.  Not sure what you're getting at with your second question?  Are you asking what I would do in that case?  I would drop my TV (though honestly everyone should probably be at that 6-8cc/kg regardless of process) and increase my expiratory times (and yes this is simplified).  

And yes.  This is how I view ventilators.  A tool.  One that should be used as infrequently and for as short as time as humanly possible.  So, yes, the moment a patient goes on the vent my very next thought is how do I get them off this damn thing as quickly and safely as possible.  

Am I concerned about patient comfort?  Of course, and I can make all kinds of great adjustments to try and improve patient comfort, though lets be honest if it were me or mine, I would just rather have some appropriate sedation/analgesia.  But that isn't what this is about.  This was about overall decision of using SIMV vs. A/C.  And where I am, with these vents, there is no difference.


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## ExpatMedic0 (May 5, 2013)

Clipper1 said:


> Off the blower?
> 
> Is this how you view ventilators?
> 
> ...



Well since you like to ask questions, I have one for you. Just who are you giving advise to other health care providers regarding ventilators on an EMS forum? Whats your background, healthcare provider level, and education? Why do you omit that information on your profile? No offense to you, but I would like to know exactly who I am getting information from here. I know some pretty crafty boy scouts with a first-aid merit badge who can site wikipedia and RRT manuals.


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## KellyBracket (May 6, 2013)

I love it - an impassioned discussion over ventilation! I'll share my amateur perspectives.

When I rotated through the medical ICU (at a tertiary/quaternary-level hospital), AC was used 98% of the time. This was the mode used in ARDSnet, it was explained to me, and so was the only evidence-based mode.

When I was in the surgical ICU, they proselytized about APRV, and its effectiveness in treating ARDS. They had to cancel a study looking at prone-positioning, in fact, since APRV ventilation cured all their patients before they could be enrolled. AC was for hayseeds, the "Devil's mode."

Of course, in the pediatric ICU, all the kiddies were on PRVC because "they aren't little adults..." Or some reason, I forget. 

So, after getting a well-rounded exposure to ventilation modes, I frankly have to agree with *Dwindlin*; ventilators are "blowers," tools to buy some time while we figure out the primary disease process. Any talk of the "best" mode is mis-framed from the onset. It's probably better to choose the "less-bad" mode!


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## Dwindlin (May 6, 2013)

KellyBracket said:


> When I was in the surgical ICU, they proselytized about APRV, and its effectiveness in treating ARDS.



I just got done spending several months in the SICU here at my school (anesthesia bound so very little time in the MICU in comparison).  I think APRV has lost its wind (pun most definitely intended) some, we only used in very bad cases when everything else failed to oxygenate the patient.  For the most part 99% of the patients were either A/C or SIMV, which ever that weeks attending was most comfortable with.


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## KellyBracket (May 6, 2013)

APRV probably fits a surgical/trauma population better - i.e. fewer co-morbid air-trapping conditions. 

I've never seen _anyone_ on SIMV!


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## Dwindlin (May 6, 2013)

KellyBracket said:


> APRV probably fits a surgical/trauma population better - i.e. fewer co-morbid air-trapping conditions.
> 
> I've never seen _anyone_ on SIMV!



Agree on the patient population.  As for the SIMV, as I've said in the discussion thus far, at least with our vents the only difference is the number of volume assisted breaths.  In A/C all of them will be, in SIMV only the "IMV" breaths.  

From what I've seen thus far the literature is a wash.  Some argue that SIMV is better since it "strengthens" the diaphragm, but again, I don't think what literature is out there bears this out.


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## Clipper1 (May 6, 2013)

ExpatMedic0 said:


> Well since you like to ask questions, I have one for you. Just who are you giving advise to other health care providers regarding ventilators on an EMS forum? Whats your background, healthcare provider level, and education? Why do you omit that information on your profile? No offense to you, but I would like to know exactly who I am getting information from here. I know some pretty crafty boy scouts with a first-aid merit badge who can site wikipedia and RRT manuals.



Years of working in critical care and doing critical care transports with various ventilators.

I wouldn't exactly compare books written by Hess and McIntyre "boy scout" manuals. That is just insulting to these professionals. 

I don't know any of your background either but sometimes by the posts you can tell if they are just BS or might actually have some idea what they are talking about. But then you might not have enough background to understand which then might lead to your own confusion.

I am on this forum because this does interest me. I have to trust you know what you are doing when you assume care for my patients which need to be transported from the ICU. I also take report from EMTs and Paramedics who bring patients.  Why do you assume what you do does not affect anyone else?  If nothing else I would like some to just find more education about ventilators and critical care. To think you know it all and no one else does it ignorant and arrogant. It also seem you want to believe EMTs and Paramedics are the only ones in health care who know anything or that the opinions and education of an RN who may have spent years in a critical care unit either stationary or mobile is useless.


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## Clipper1 (May 6, 2013)

Dwindlin said:


> I just got done spending several months in the SICU here at my school (anesthesia bound so very little time in the MICU in comparison).  I think APRV has lost its wind (pun most definitely intended) some, we only used in very bad cases when everything else failed to oxygenate the patient.  For the most part 99% of the patients were either A/C or SIMV, which ever that weeks attending was most comfortable with.



What ventilators are you using?  What is the triggering mechanism? Demand or continuous flow? 

APRV is very popular.  Did you know it delivers two levels of pressure at extended time periods while allowing someone to breathe spontaneously at both levels? For someone who believes in pressure support this should be a dream come true for you.



Dwindlin said:


> Agree on the patient population.  As for the SIMV, as I've said in the discussion thus far, at least with our vents the only difference is the number of volume assisted breaths.  In A/C all of them will be, in SIMV only the "IMV" breaths.
> 
> From what I've seen thus far the literature is a wash.  Some argue that SIMV is better since it "strengthens" the diaphragm, but again, I don't think what literature is out there bears this out.



When you read the literature you should take note on what the patient disease process it.  

Also, as I mentioned before and the textbooks quoted have and any other site explaining SIMV will, the difference will also be in the flow delivery.  You also must understand that the PSV breaths associated with the SIMV mode will be compliance dependent. They will also vary with just a tiny bit of secretions.  This can make a big difference in the VT delivered and might be inadequate to maintain a decent minute volume. The patient will also have to work harder to get the VT for the MV they want.


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## Clipper1 (May 6, 2013)

KellyBracket said:


> .
> 
> When I was in the surgical ICU, they proselytized about APRV, and its effectiveness in treating ARDS. They had to cancel a study looking at prone-positioning, in fact, since APRV ventilation cured all their patients before they could be enrolled. AC was for hayseeds, the "Devil's mode."



APRV is a spontaneous mode. It can be used only if the patients can initiate all their breaths. AC does not have that requirements. APRV (BiLEVEL on some vents) definitely has its purpose when sedation is lightened and they can maintain adequate volumes with the PSV breaths at both pressure levels to stay with an ARDS protocols. 



KellyBracket said:


> .
> Of course, in the pediatric ICU, all the kiddies were on PRVC because "they aren't little adults..." Or some reason, I forget.



APRV is not PRVC.  Kids should not be ventilated with high pressures but some may need a more consistent VT which might have a large variance due to compliance.

Do you know how many different ventilators and modes there are for all the different diseases? Believe it or now but just one mode doesn't always work for everyone.


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## Clipper1 (May 6, 2013)

Dwindlin said:


> *Puritan Bennett 840*.  Not sure what you're getting at with your second question?  Are you asking what I would do in that case?  I would drop my TV (though honestly everyone should probably be at that 6-8cc/kg regardless of process) and increase my expiratory times (and yes this is simplified).
> 
> And yes.  This is how I view ventilators.  A tool.  One that should be used as infrequently and for as short as time as humanly possible.  So, yes, the moment a patient goes on the vent my very next thought is how do I get them off this damn thing as quickly and safely as possible.
> 
> Am I concerned about patient comfort?  Of course, and I can make all kinds of great adjustments to try and improve patient comfort, though lets be honest if it were me or mine, I would just rather have some appropriate sedation/analgesia.  But that isn't what this is about.  This was about overall decision of using SIMV vs. A/C.  And where I am, with these vents, there is no difference.



Where are you using the PB 840? This is an ICU ventilator.  PB 840 also uses the term BiLevel and not APRV.   

Saying all patients should be on 6 - 8 ml will depend on the ventilator and the patient.  If the machine is able to adjust for compressible volume loss the great.  If it is a single limb transport ventilator you might think you are giving 6 cc but might only be giving 2 - 3 ml.

The lack of understanding of the disease process, the age differences (children, adult, geriatric), ventilator concepts and the ventilator you are using is what makes people get stuck on a ventilator.

When some use SIMV the patient get stuck on the vent for more days than they should as they drop the mandatory rate slowly.  With AC they so spontaneous breathing trials every day by just placing the patient on PSV to exercise their breathing. Some might even just go to flow by to mimic a t-piece trial.  The flow patterns are less irregular and the wean is quicker which is as soon as the patient achieves a consistent spontaneous effort. I can't imagine any doctor wanting to keep a patient in PACU for days as they walk down the SIMV rate. Maybe this is why some ICUs are full and why their vent days are long when compared to other hospitals.

BTW, the correct abbreviation for ventilator volume is ml and not cc.


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## Aidey (May 6, 2013)

Clipper1 said:


> Years of working in critical care and doing critical care transports with various ventilators.



You still didn't answer his question. It says right in Expatmedic's profile that he is a NRP, a nationally registered Paramedic. We still have no idea what your training/education level is.


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## Clipper1 (May 6, 2013)

Aidey said:


> You still didn't answer his question. It says right in Expatmedic's profile that he is a NRP, a nationally registered Paramedic. We still have no idea what your training/education level is.



I thought I had made that clear in some of my previous posts. Others have figured it out.

RN - Registered Nurse 

This is an anonymous forum. Why do you make some post their credentials and not others?  If you want specifics this should be a closed forum and the license numbers used for ID like the critical care and professional association forums.

You should not single out members because of your own bias against nurses or anyone else who is not an EMT or Paramedic. There are other professionals who are involved in EMS on a daily bases either directly or indirectly.


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## RocketMedic (May 6, 2013)

Um...I dont understand a lot of the terminology tossed about here, but here goes. At EMSA, I had an AEV Impact 731 with CPAP, BiPAP, AC and SIMV. I generally used AC with my underlying rate set at 12, volume to 6-8mL per ideal kg, pressure set to 40. Now at REACT, I have a pneumatic ParaPack vent with only a rate, volume, max pressure and two-position FiO2. CPAP is a separate unit, CPAP only. How do I use this as anything other than a BVM?


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## Clipper1 (May 6, 2013)

Rocketmedic40 said:


> I have a pneumatic ParaPack vent with only a rate, volume, max pressure and two-position FiO2. CPAP is a separate unit, CPAP only. How do I use this as anything other than a BVM?



This ventilator has a more sensitive triggering mechanism for it to function in the AC mode by delivering each breath requested. But you can also adjust ITime to increase rate and allow more flow.  This ventilator is actually comfortable for spontaneously breathing patients. But, it is at a disadvantage for CC patients if it doesn't have graphics unless you know the patient well which is why it is popular for inhouse transports and it is MRI compatible.  We do have a couple for inhouse along with the LTV 1200s which are used for the ER Trauma/Resus bays and more complex ICU transports to CT Scan, OR etc.

The Autovent which was mentioned earlier only gives the set rate at the I:E and does not vary which is why the patient must not breathe spontaneous.


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## Aidey (May 6, 2013)

Clipper1 said:


> I thought I had made that clear in some of my previous posts. Others have figured it out.
> 
> RN - Registered Nurse
> 
> ...



We don't make some post their credentials and not others. It is fully within the right of the membership to request someone reveal their level of training, however we won't make people comply. There is nothing wrong with wanting to know where information is coming from. 

How can we single out members and have a bias against someone who isn't an EMT or Paramedic if we have no idea what their training level is? From reading your posts you could have been anything from an EMT going through nursing school to a Nurse Anesthetist.


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## ExpatMedic0 (May 6, 2013)

Well thank you for your advise and also your information regarding the topic on vent modes. Your more than welcome to participate in topics on the EMS forum as an RN, so please do not worry about that.

Since you where kind enough to offer advise, I would like to repay the favor. My advise to you from one provider to another.... If your bedside manner is anything like your persona on here, my advise to you would be to work on that. That is not a personal attack on you, its just your coming across a little harsh in most of your post, maybe you do not even realize it. No need to have a superiority complex and put down others. No one should be afraid to post information on this forum.

Secondly, If you would like to share knowledge and give advise to other health care providers on here, its helpful for us to know who we are speaking with. There are  some extremely knowledgeable EMT Basics and even patients who post material on this forum. I do not see why you are so reluctant to brandish your RN title. 

If you would like to participate in discussions and share your knowledge I think that is great. I might even learn a thing or to, I am not ashamed to admit that. However, if I (or many of the others) are to take you seriously, and not just as a troll, maybe turn that frown upside down a little :wub:




Clipper1 said:


> I thought I had made that clear in some of my previous posts. Others have figured it out.
> 
> RN - Registered Nurse
> 
> ...


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## ExpatMedic0 (May 6, 2013)

Clipper1 said:


> I don't know any of your background either but sometimes by the posts you can tell if they are just BS or might actually have some idea what they are talking about. But then you might not have enough background to understand which then might lead to your own confusion.
> 
> To think you know it all and no one else does it ignorant and arrogant. It also seem you want to believe EMTs and Paramedics are the only ones in health care who know anything or that the opinions and education of an RN who may have spent years in a critical care unit either stationary or mobile is useless.



Well I am not sure if I should be flattered that you are actually taking the time to read my post, or insulted. 
I do not know it all, far from it..... the thing is... I can admit that with a smile on my face


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## Clipper1 (May 6, 2013)

ExpatMedic0 said:


> Well thank you for your advise and also your information regarding the topic on vent modes. Your more than welcome to participate in topics on the EMS forum as an RN, so please do not worry about that.
> 
> Since you where kind enough to offer advise, I would like to repay the favor. My advise to you from one provider to another.... If your bedside manner is anything like your persona on here, my advise to you would be to work on that. That is not a personal attack on you, its just your coming across a little harsh in most of your post, maybe you do not even realize it. No need to have a superiority complex and put down others. No one should be afraid to post information on this forum.
> 
> ...



What's with the double standard?  Your post says it all.  "Gee the mean nurse is picking on the EMTs and Paramedics again".  If you can't stand your ground through showing reason you resort to personal attacks.  That also includes some of forum managers. 

One thing I can not stand is those who argue about something but haven't read what they have posted as a reference which clearly contradicts what they are stating or those who refuse to seek out more than hearsay or what they have read on these anonymous open forums.

I and my profession have been bashed here and I have tried to play nice.  I must reveal my credentials but I don't see others being made to do the same every time they come to post. 

If I do put up my full credentials I will be bashed for showing off education. Also, I have already taken note here how those who have put RN on their profile are treated here.

It truly is a no win situation for RNs on these forums. Nursing sites don't have any objection when an EMT or Paramedic enters a discussion.


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## Aidey (May 6, 2013)

Clipper1 said:


> What's with the double standard?  Your post says it all.  "Gee the mean nurse is picking on the EMTs and Paramedics again".  If you can't stand your ground through showing reason you resort to personal attacks.  That also includes some of forum managers.
> 
> One thing I can not stand is those who argue about something but haven't read what they have posted as a reference which clearly contradicts what they are stating or those who refuse to seek out more than hearsay or what they have read on these anonymous open forums.
> 
> ...



There is no double standard, Expat was trying to be helpful and give you advice on how to communicate better so that your posts don't come off as abrasive. No one is accusing RNs of picking on EMTs and Paramedics. No one is bashing you or RNs. You were not forced to reveal your credentials, it was a polite request that you could have easily refused. No one is ever going to "bash" someone for having a good education. 

I think if you ask the other RNs and RN students on this board, they will not report the same feeling of persecution like you seem to feel.


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## ExpatMedic0 (May 6, 2013)




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## RocketMedic (May 6, 2013)

I don't think EMTLife is a forum where we criticize people for being educated, Clipper1.


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## RocketMedic (May 6, 2013)

Clipper1 said:


> This ventilator has a more sensitive triggering mechanism for it to function in the AC mode by delivering each breath requested. But you can also adjust ITime to increase rate and allow more flow.  This ventilator is actually comfortable for spontaneously breathing patients. But, it is at a disadvantage for CC patients if it doesn't have graphics unless you know the patient well which is why it is popular for inhouse transports and it is MRI compatible.  We do have a couple for inhouse along with the LTV 1200s which are used for the ER Trauma/Resus bays and more complex ICU transports to CT Scan, OR etc.
> 
> The Autovent which was mentioned earlier only gives the set rate at the I:E and does not vary which is why the patient must not breathe spontaneous.



http://www.smiths-medical.com/catal...eupac/para-pac/pneupac-parapac-mri-p200d.html

That's what I have to work with, coming from http://www.impactinstrumentation.com/731.html . 

How do I adjust I:E time on the Parapac? This thing literally only lets me set pressure, rate and FiO2.


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## shfd739 (May 6, 2013)

Rocketmedic40 said:


> http://www.smiths-medical.com/catal...eupac/para-pac/pneupac-parapac-mri-p200d.html
> 
> That's what I have to work with, coming from http://www.impactinstrumentation.com/731.html .
> 
> How do I adjust I:E time on the Parapac? This thing literally only lets me set pressure, rate and FiO2.



Looks like the Parapac is a set IE with no way to adjust. 

We just got the 731s to replace 754s..So nice and can be setup/tweaked for the majority of the patients we transport. Wasnt always the case with the 754s.


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## Carlos Danger (May 6, 2013)

Aidey said:


> I think if you ask the other RNs and RN students on this board, they will not report the same feeling of persecution like you seem to feel.



Persecution? No.

A bit of a double standard, in terms of how little RN-->medic criticism is tolerated vs. medic-->RN criticism? Yeah, I'd say so. 

I suppose it's understandable though, this being an EMS forum and all.


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## Carlos Danger (May 6, 2013)

The best vent mode is dependent on the clinical situation. In most cases, it really doesn't matter if you do AC vs. SIMV vs. PRVC, or even pressure vs. volume limited. Assuming set parameters are reasonable, of course.

We used an LTV-1200 on most transports and I found SIMV to work well in most patients, usually volume limited but pressure limited was sometimes helpful. Pressure support was helpful in some patients, as well. 

We also had a Maquet Servo-i available. During the swine flu outbreak a few years ago, I transported some of the sickest patients I've ever seen on the Servo-i. Often they would ventilate much better on APRV than on the PRVC that we usually found them on at the referring facility.


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